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psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Why are medical errors still a leading cause of death?
April 19, 2017
Headley M.
https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
This magazine article explores the need for robust research and effective reporting to better understand the
prevalence of medical errors and how to prevent…
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psnet.ahrq.gov/node/60309/psn-pdf
May 06, 2020 - COVID-19 leads to increased need for dialysis machines.
May 6, 2020
Mosley T. Here & Now. Boston Public Radio. April 27, 2020.
https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines
Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for
…
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psnet.ahrq.gov/node/44239/psn-pdf
September 29, 2017 - When medical care leads to harm—difficulty finding
words: a teachable moment.
September 29, 2017
Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a
teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/844553/psn-pdf
February 15, 2023 - Mental health conditions leading cause of pregnancy-
related deaths.
February 15, 2023
Quick Safety. January 16 2023;(67):1-3.
https://psnet.ahrq.gov/issue/mental-health-conditions-leading-cause-pregnancy-related-deaths
Maternal safety is compromised by a range of social, cognitive, and clinical factors. This arti…
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psnet.ahrq.gov/node/38598/psn-pdf
June 03, 2010 - Leading successful rapid response teams: a multisite
implementation evaluation.
June 3, 2010
Donaldson N, Shapiro S, Scott M, et al. Leading successful rapid response teams: A multisite
implementation evaluation. J Nurs Adm. 2009;39(4):176-81. doi:10.1097/NNA.0b013e31819c9ce9.
https://psnet.ahrq.gov/issue/leading-…
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psnet.ahrq.gov/node/73498/psn-pdf
July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the
patient leads to a tragic error
July 14, 2021
ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.
https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
High-alert medication misadministration i…
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psnet.ahrq.gov/node/43201/psn-pdf
May 21, 2014 - New HHS Data Shows Major Strides Made in Patient
Safety, Leading to Improved Care and Savings.
May 21, 2014
Washington, DC: US Department of Health and Human Services; May 7, 2014.
https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved-
care-and-savings
Comparing safety…
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psnet.ahrq.gov/node/45357/psn-pdf
October 09, 2016 - Leading article: how can I optimise my role as a leader
within the surgical team?
October 9, 2016
Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the
surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035.
https://psnet…
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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…
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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…
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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…
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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…
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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 …
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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…
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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…
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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…
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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…
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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…
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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…
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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…