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841. Which Line: Ordering Provider or Proceduralist? | PSNet
     psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
     September 16, 2015 - Communication errors between the ordering provider and radiology can lead to a range of adverse events … or electronic) processes, resilient systems are designed to identify and correct errors before they lead

842. When COVID-19 hit, many elderly were left to die. | PSNet
     psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
     June 24, 2020 - Newspaper/Magazine Article When COVID-19 hit, many elderly were left to die. Citation Text: Stevis-Gridneff M, Apuzzo M, Pronczuk M. When COVID-19 hit, many elderly were left to die. New York Times. 2020;August 8. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

843. Debriefing in the emergency department after clinical events: a practical guide. | PSNet
     psnet.ahrq.gov/issue/debriefing-emergency-department-after-clinical-events-practical-guide
     November 16, 2022 - Commentary Debriefing in the emergency department after clinical events: a practical guide. Citation Text: Kessler DO, Cheng A, Mullan PC. Debriefing in the Emergency Department After Clinical Events: A Practical Guide. Ann Emerg Med. 2015;65(6):690-698. doi:10.1016/j.annemergmed.2014.10…

844. Unintended Consequences of CPOE | PSNet
     psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
     September 01, 2004 - List common design flaws in the development of picklists that may lead to errors. … review found that CPOE with decision support did not prevent adverse drug events.( 3 ) Although CPOE did lead … Research has shown that poor usability can lead to adverse events in health care.

845. Overuse as a Patient Safety Problem | PSNet
     psnet.ahrq.gov/perspective/overuse-patient-safety-problem
     September 01, 2014 - generating excess diagnoses or additional treatments, which in turn creates "more to do" and ultimately can lead … long-lasting, psychological impacts on patients.( 11 ) To make matters worse, false-positive tests typically lead … of Accountable Care Organizations, may help incentivize systemic solutions for coordinating care and lead

846. Patient Safety and Opioid Medications | PSNet
     psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
     January 01, 2015 - Of course, there is also a risk that aggressive policies to restrict opioid use will lead to new harms … approaches to address opioid use as a patient safety problem and work to ensure that these approaches lead

847. The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns | PSNet
     psnet.ahrq.gov/issue/co-design-implementation-and-evaluation-serious-board-game-playdecide-patient-safety-educate
     September 12, 2018 - September 12, 2018 The Collective Leadership for Safety Culture (Co-Lead) team intervention

848. Situational (Un)Awareness | PSNet
     psnet.ahrq.gov/web-mm/situational-unawareness
     August 01, 2009 - The Commentary Medication errors are the most frequent type of medical error and can lead to significant … Research by Ash and colleagues found that implementation of CPOE can lead to overdependence on technology

849. Dangerous Dapsone | PSNet
     psnet.ahrq.gov/web-mm/dangerous-dapsone
     January 10, 2011 - care.( 7 ) Data on cisapride dispensing further confirms that a lack of environmental control may lead … Communication problems may lead to errors.

850. Building a Safety Program Using Principles of Resilience Engineering | PSNet
     psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
     October 23, 2013 - However, a push for efficiency can lead to unanticipated effects on safety, as resources (such as staff … For instance, the push for maximizing operating room (OR) utilization can sometimes lead OR coordinators

851. Beware of basal opioid infusions with PCA therapy. | PSNet
     psnet.ahrq.gov/issue/beware-basal-opioid-infusions-pca-therapy
     June 05, 2018 - Newspaper/Magazine Article Beware of basal opioid infusions with PCA therapy. Citation Text: Beware of basal opioid infusions with PCA therapy. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3. Copy Citation Save Save to your library P…

852. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. | PSNet
     psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-third-edition
     May 04, 2016 - Book/Report Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. Citation Text: Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259. Copy…

853. Rethinking Patient Safety. | PSNet
     psnet.ahrq.gov/issue/rethinking-patient-safety
     April 13, 2018 - Book/Report Rethinking Patient Safety. Citation Text: Rethinking Patient Safety. Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitte…

854. Editorial Team | PSNet
     psnet.ahrq.gov/Information/Editor
     Barnes is the physician lead for a bold initiative to bring AHRQ's TeamSTEPPS program to all physicians … Roslyn has previously served as associate lead for quality and supported projects across 3 urban emergency

855. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet
     psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
     May 04, 2016 - Book/Report Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. Citation Text: Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. M…

856. Education outcomes from a duty-hour flexibility trial in internal medicine. | PSNet
     psnet.ahrq.gov/issue/education-outcomes-duty-hour-flexibility-trial-internal-medicine
     December 12, 2012 - August 2, 2015 Did duty hour reform lead to better outcomes among the highest risk patients

857. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. | PSNet
     psnet.ahrq.gov/issue/missed-diagnoses-acute-myocardial-infarction-emergency-department-variation-patient-and
     April 08, 2018 - 2018 WebM&M Cases Missing ECG and Missed Diagnosis Lead

858. The ongoing quality improvement journey: next stop, high reliability. | PSNet
     psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
     January 23, 2012 - Commentary The ongoing quality improvement journey: next stop, high reliability. Citation Text: Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-68. doi:10.1377/hlthaff.2011.0076. Copy Citation Format…

859. Good Night's Sleep Gone Wrong | PSNet
     psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
     September 01, 2015 - pharmacokinetics of many medications change due to slower metabolism and decreased clearance, which can lead … electronic provider order entry systems with insomnia orders sets to guide clinical decision-making may lead

860. Emergency department visits for antibiotic-associated adverse events. | PSNet
     psnet.ahrq.gov/issue/emergency-department-visits-antibiotic-associated-adverse-events
     October 31, 2014 - Study Emergency department visits for antibiotic-associated adverse events. Citation Text: Shehab N, Patel PR, Srinivasan A, et al. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008;47(6):735-43. doi:10.1086/591126. Copy Citation Format: …