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  1. Radiology Missed an Intracranial Bleed in a Lethargic Infant. | PSNet

    psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
    August 21, 2016 - AHT occurs from direct impact to the head, shaking, or a combination of both, and can lead to serious

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - most common category of surgical never events.1 Never events are serious and costly errors that may lead

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866995/psn-pdf
    October 30, 2024 - EHRs with poor user interfaces lead to provider fatigue6 and probably detract from available time to

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - combination of pills of different strengths with interrupted daily or weekly treatment cycles can lead

  5. Volume Too Low: In and Out | PSNet

    psnet.ahrq.gov/web-mm/volume-too-low-and-out
    July 01, 2017 - liquid suspensions, pharmacists may have to manually prepare suspensions by crushing tablets, which can lead

  6. A Double “Never Event”: Wrong Patient and Wrong Side. | PSNet

    psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
    August 20, 2018 - June 10, 2013 Did duty hour reform lead to better outcomes among the highest risk patients

  7. Bad Writing, Wrong Medication | PSNet

    psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
    March 01, 2015 - Error Reporting and Prevention defines a medication error as "any preventable event that may cause or lead

  8. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-292
    May 26, 2021 - Distractions in the operating room are common and can lead to errors.

  9. In Conversation With... Michael L. Millenson | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-l-millenson
    April 27, 2022 - million to the Agency for Healthcare Research and Quality (AHRQ), which was designated as the federal lead

  10. The Media’s Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/medias-role-patient-safety
    April 27, 2022 - million to the Agency for Healthcare Research and Quality (AHRQ), which was designated as the federal lead

  11. Lesson from the VA's Team Training Program | PSNet

    psnet.ahrq.gov/perspective/lesson-vas-team-training-program
    November 01, 2011 - I think we're finding a lot more about the brain and how firing A will lead to B.

  12. In Conversation With… David Juurlink, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
    May 22, 2017 - June 25, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

  13. In Conversation with…Gerald B. Hickson, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
    December 01, 2009 - brought to the individual's attention, awareness as to perceptions and assumptions about the event lead

  14. How to Identify and Manage Problem Behaviors | PSNet

    psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
    December 01, 2009 - brought to the individual's attention, awareness as to perceptions and assumptions about the event lead

  15. Code Status vs. Care Status | PSNet

    psnet.ahrq.gov/web-mm/code-status-vs-care-status
    September 30, 2020 - And communication failures often lead to patient harm, as they did in the care of this patient. 

  16. In Conversation With… Andrew Gettinger, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
    September 01, 2017 - In Conversation With… Andrew Gettinger, MD September 1, 2017  Also Read an Essay Citation Text: In Conversation With… Andrew Gettinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  17. Opioid Overdose as a Patient Safety Problem | PSNet

    psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
    May 01, 2017 - June 25, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

  18. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
    February 26, 2025 - : Awareness of potential for failure and emergence of new threats so that absence of error does not lead

  19. High Reliability Organization (HRO) Principles and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
    February 26, 2025 - : Awareness of potential for failure and emergence of new threats so that absence of error does not lead

  20. In Conversation With… Eduardo Salas, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
    November 01, 2011 - I think we're finding a lot more about the brain and how firing A will lead to B.
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