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4621. 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…

4622. CE/MOC Quizzes | PSNet
      psnet.ahrq.gov/cme
      February 26, 2025 - The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect

4623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40055/psn-pdf
      December 01, 2010 - Parkland knee surgery done by doctor in training leads to amputation, questions. December 1, 2010 Egerton B. Dallas Morning News. November 14, 2010;A01. https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions This newspaper article investigates how surgical errors and pos…

4624. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39825/psn-pdf
      June 10, 2018 - Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1-3. https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error This article discusses a case …

4625. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet
      psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
      March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

4626. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45113/psn-pdf
      May 11, 2016 - Medical error—the third leading cause of death in the US. May 11, 2016 Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. doi:10.1136/bmj.i2139. https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us How many patients die each year due to preventabl…

4627. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73097/psn-pdf
      March 31, 2011 - The Future of Nursing: Leading Change, Advancing Health. March 31, 2011 Institute of Medicine. Washington, DC: The National Academies Press: 2011. https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health The effective engagement of nursing is key to patient safety and care quality improvement. T…

4628. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45005/psn-pdf
      May 04, 2016 - Leading High-Reliability Organizations in Healthcare. May 4, 2016 Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883. https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare High reliability has been recently adopted as a goal for health care. This book reviews the primar…

4629. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/866843
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Falls Prevention Awareness Week 2024 Curated Library Primers Falls September, 7 2019 Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coo…

4630. ISMP updates its list of drug name pairs with Tall man letters. | PSNet
      psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
      June 10, 2018 - Interruptions lead to errors and unfinished…wait, what was I doing?

4631. Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? | PSNet
      psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways-prevent-mix-ups
      June 10, 2018 - November 3, 2015 Drawn curtains, muted alarms, and diverted attention lead to tragedy

4632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44363/psn-pdf
      May 05, 2018 - Selection of incorrect medication pump leads to chemotherapy overdose. May 5, 2018 ISMP Canada. August 26, 2015;15:1-4. https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. I…

4633. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34659/psn-pdf
      April 07, 2010 - Leading change: why transformation efforts fail. April 7, 2010 Kotter JP. Harvard Bus Rev  1995;73(2);59-67. https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process, as well a…

4634. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44303/psn-pdf
      January 10, 2018 - Leading Health Care Transformation: A Primer for Clinical Leaders. January 10, 2018 Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders Leadership can enable the change needed to address heal…

4635. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45565/psn-pdf
      May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success. May 24, 2017 Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success Health care leadership plays an undeniable role in sust…

4636. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44183/psn-pdf
      November 03, 2015 - The absence of a drug–disease interaction alert leads to a child's death. November 3, 2015 ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4. https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death The disabling of alerts due to alarm fatigue can hinder the abilit…

4637. Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. | PSNet
      psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural
      May 13, 2009 - December 14, 2007 Does increased schedule flexibility lead to change?

4638. Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. | PSNet
      psnet.ahrq.gov/issue/implementing-interprofessional-patient-safety-learning-initiative-insights-participants
      August 14, 2014 - Study Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. Citation Text: Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights fr…

4639. Oral chemotherapy: not just an ordinary pill. | PSNet
      psnet.ahrq.gov/issue/oral-chemotherapy-not-just-ordinary-pill
      May 05, 2018 - Newspaper/Magazine Article Oral chemotherapy: not just an ordinary pill. Citation Text: Oral chemotherapy: not just an ordinary pill. ISMP Canada. SafeMedicineUse. August 19, 2015;6:1-2. Copy Citation Save Save to your library Print Download PDF …

4640. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. | PSNet
      psnet.ahrq.gov/issue/adverse-events-cough-and-cold-medications-after-market-withdrawal-products-labeled-infants
      August 02, 2015 - Study Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Citation Text: Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Pediatrics. 20…