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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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 …
  3. Psn-Pdf (pdf file)

    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/…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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-…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. 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…
  10. 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…
  11. 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…
  12. 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…
  13. 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 …
  14. 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…
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. 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…
  20. 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…

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