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401. Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. | PSNet
     psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-potential-medication-errors
     October 09, 2013 - , 2013 Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead … Differences in strength expression on product labels of compounders and conventional manufacturers may lead

402. Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. | PSNet
     psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-improve-safety
     August 08, 2018 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead

403. Drug shortages continue to compromise patient care. | PSNet
     psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
     February 24, 2016 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … June 27, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49556/psn-pdf
     March 01, 2008 - What appears to be a simple and straightforward order can lead to a variety of breakdowns in the medication … administration process and potentially lead to patient harm, as it did in this case. … For example, oral medications for diabetes (which can lead to hypoglycemia if patients are not eating … Take-Home Points Temporary hold orders can lead to multiple errors and complications in the medication … Hold orders can lead to problems with medication prescribing, transcription, or order entry.

405. Introduction to the SPPC‐II Teamwork Toolkit for Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_1-introduction-speaker-notes.pdf
     July 01, 2023 - basics o Teamwork tool specifics o Implementation guidance • Organize frontline participation • Lead … We will help you organize frontline participation and teach you how to lead the facilitation sessions … Ultimately, it is your responsibility as a Hospital AIM Team Lead to enable and encourage your frontline

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49572/psn-pdf
     October 01, 2008 - In some cases, incorrect identification may lead primarily to provider embarrassment without any patient … On the other hand, many instances of patient identification errors lead to more than embarrassment—such … errors can lead to serious harm or even loss of life. … Patient identification errors occur at least occasionally in virtually every health system, and some lead … Language barriers may lead to misidentification and increase the likelihood of adverse events.

407. Introduction _x000b_to the SPPC-II Teamwork Toolkit _x000b_for Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction.pptx
     July 01, 2023 - workshop Teamwork basics Teamwork tool specifics Implementation guidance Organize frontline participation Lead … We will help you organize frontline participation and teach you how to lead the facilitation sessions … Ultimately, it is your responsibility as a Hospital AIM Team Lead to enable and encourage your frontline

408. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45452/psn-pdf
     August 24, 2016 - administration methods used to reduce device costs can introduce heightened potential for dosing errors and lead

409. Procedure Manual Section 1. Overview of U.S. Preventive Services Task Force Structure and Processes | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-1
     December 01, 2013 - Member may participate as primary lead, and may discuss and vote on the topic 3 Any relevant financial … for topic workgroup Member may not participate as the primary lead of the topic workgroup specific to … the conflict, but may serve as a lead on the topic workgroup and discuss and vote on the topic. … Member may not serve as a lead on the topic workgroup Member may not participate as a lead in the topic … Recusal from all participation in topic activities Member may not participate as a lead on the topic

410. Introduction to the SPPC‐II Teamwork Toolkit for Obstetric Hemorrhage (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_1-introduction-speaker-notes.pdf
     July 01, 2023 - guidance minutes per online module • Organize frontline participation o Self‐directed and self‐paced • Lead … We will help you organize frontline participation and teach you how to lead the facilitation sessions … Ultimately, it is your responsibility as a Hospital AIM Team Lead to enable and encourage your frontline

411. Medical device alarm safety in hospitals. | PSNet
     psnet.ahrq.gov/issue/medical-device-alarm-safety-hospitals
     December 23, 2016 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … June 20, 2018 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

412. The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries. | PSNet
     psnet.ahrq.gov/issue/impact-resident-duty-hour-reform-hospital-readmission-rates-among-medicare-beneficiaries
     November 26, 2014 - July 1, 2009 Did duty hour reform lead to better outcomes among the highest risk patients … May 25, 2011 Did duty hour reform lead to better outcomes among the highest risk patients

413. Horizon Scanning Protocol and Operations Manual January 2013 Revision (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/ahrq-healthcare-horizon-scan-protocol-operations-manual_130826.pdf
     August 01, 2013 - New – The lead was recently uploaded and has not yet been reviewed by an analyst. 7. … The analyst provides a brief rationale for discarding the lead. 10. … The analyst provides a brief rationale for archiving the lead (e.g., the lead is out-of-date, superseded … by another lead). 11. … The analyst may then use various tags to further classify the lead (e.g., lead source, manufacturer

414. Microsoft Word - SummaryRpt_Appendixes_Final.doc (pdf file)
     digital.ahrq.gov/sites/default/files/docs/page/privacy-and-security-solutions-for-interoperable-hie-nationwide-summary-appendices.pdf
     July 01, 2007 - tity Vendor No CalRYes HIO http://www.c  Lead entity HIEs, including identified; board selection  … at Flor Sevida Yes era otherl Completed Lead Early steps No FHINYes Flor, http:ida //ahca.  Lead entity … Name, Origin Website Statewide HIE Maine Yes Health IT and Completed Lead Vendor No MainYes e http: … G active — participant S Massachu- regYes Some ional Completed Lead Participated in No Yes … elo role: lead p m convener (continued) en t o f H IT /H IE A cro ss H IS PC -Particip

415. Supporting Clinical Staff Who Prescribe Opioids to Older Adults: Providing Targeted Educational Sessions to Meet Needs Case Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-prescribe-opioids.pdf
     June 02, 2025 - ■ A special training of trainers for a small group of nurse leaders who can act as champions and “lead

416. Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors. | PSNet
     psnet.ahrq.gov/issue/anticipated-consequences-2011-duty-hours-standards-views-internal-medicine-and-surgery
     August 22, 2018 - August 22, 2018 Did duty hour reform lead to better outcomes among the highest risk patients … April 24, 2018 Does increased schedule flexibility lead to change?

417. Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
     July 01, 2023 - Tier 2 – AIM Team Lead Education Relying on a train-the-trainer model, the goal is to empower AIM Team

418. CDS Repository Working Group Charter (pdf file)
     cds.ahrq.gov/sites/default/files/cds/artifact/476/CDS%20Pain%20Management%20Summary%20Quick%20Start%20Guide_final_1.pdf
     July 23, 2024 - Matt Wheeler, Pilot Project Leader (wheelerm@ochin.org) MITRE Contacts: Ginny Meadows, Deputy Pilot Lead … (jmeadows@mitre.org), Sharon Sebastian, Project and Pilot Lead, (sharon@mitre.org) Page 2 https:

419. Mistaken Identity | PSNet
     psnet.ahrq.gov/web-mm/mistaken-identity
     December 18, 2014 - In some cases, incorrect identification may lead primarily to provider embarrassment without any patient … On the other hand, many instances of patient identification errors lead to more than embarrassment—such … errors can lead to serious harm or even loss of life. … Patient identification errors occur at least occasionally in virtually every health system, and some lead … Language barriers may lead to misidentification and increase the likelihood of adverse events.

420. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36626/psn-pdf
     January 14, 2011 - https://psnet.ahrq.gov/issue/whats-trouble-how-doctors-think The author discusses how heuristics can lead