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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46304/psn-pdf
     November 01, 2017 - comparative-performance-pediatric-weight-estimation-techniques-human- factor-errors-analysis Estimating weights in time-sensitive situations can lead

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45705/psn-pdf
     January 23, 2017 - provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46354/psn-pdf
     November 21, 2017 - controlled-trial-improve-resident-sign-out-medical-intensive-care-unit Communication errors during handoffs can lead

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43250/psn-pdf
     December 01, 2016 - found that children with complex chronic conditions are at higher risk for adverse drug events that lead

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46413/psn-pdf
     February 22, 2018 - comparison-error-rates-between-intravenous-push-methods-prospective- multisite-observational Errors in intravenous medication administration can lead

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35127/psn-pdf
     February 24, 2011 - health care providers represent a critical information source to better understand the systems that lead

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46697/psn-pdf
     January 10, 2018 - ://psnet.ahrq.gov/issue/primary-care-providers-perspectives-errors-omission Errors of omission can lead

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35069/psn-pdf
     June 22, 2009 - towards-organization-memory-exploring-organizational-generation-adverse- events-health-care The authors examine the organizational factors that lead

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45173/psn-pdf
     November 18, 2016 - Prior analyses have suggested that HACs lead to nearly $150 million per year in excess Medicare costs

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44479/psn-pdf
     September 09, 2015 - https://psnet.ahrq.gov/issue/health-literacy-primary-care-practice Limited health literacy can lead

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35669/psn-pdf
     July 08, 2008 - The authors conclude with a call to action for organizations best positioned to lead this charge, including

472. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. | PSNet
     psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care
     May 18, 2022 - Commentary Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. Citation Text: Clarke CM, Persaud DD. Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. doi:10.1097/pts.0b013e31820c98a8. Copy Citation …

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47094/psn-pdf
     June 13, 2018 - functional-decline-associated-polypharmacy-and-potentially-inappropriate-medications https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44937/psn-pdf
     September 29, 2017 - Antibiotics are a significant source of medical care overuse and inappropriate prescriptions can lead

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47217/psn-pdf
     June 27, 2018 - drug-shortages-continue-compromise-patient-care https://psnet.ahrq.gov/issue/other-opioid-crisis-hospital-shortages-lead-patient-pain-medical-errors

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47068/psn-pdf
     June 25, 2018 - need-closed-loop-systems-management-abnormal-test-results Failure to follow up abnormal test results can lead

477. The absence of a drug–disease interaction alert leads to a child's death. | PSNet
     psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
     July 08, 2015 - July 29, 2020 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

478. Hindsight Bias | PSNet
     psnet.ahrq.gov/glossary/hindsight-bias
     September 13, 2021 - Hindsight Bias September 13, 2021 Anonymous (not verified) In a very general sense, hindsight bias relates to the common expression "hindsight is 20/20." This expression captures the tendency for people to regard past events as expected or obvious, even when, in real time, the events perplexed those involved. M…

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38051/psn-pdf
     May 05, 2018 - Misprogramming PCA concentration leads to dosing errors. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes dosing errors associated with improper concentration programming of…

480. Making hospital care safer and better: the structure-process connection leading to adverse events. | PSNet
     psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading-adverse-events
     November 04, 2020 - Study Making hospital care safer and better: the structure-process connection leading to adverse events. Citation Text: El-Jardali F, Lagacé M. Making hospital care safer and better: the structure-process connection leading to adverse events. Healthc Q. 2005;8(2):40-8. Copy Citation …