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  1. Errors in Paramedic Endotracheal Intubation (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006Wang_051611comp.pdf
    January 01, 2006 -  Highlight how studies of ETI errors have lead to broader questions regarding the structure, nature … Pittsburgh School of Medicine - Department of Emergency Medicine “How Can a Life-Saving Intervention Lead …  Scientific data does not lead to change in practice.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36587/psn-pdf
    January 14, 2011 - authors describe a tissue specimen marking mechanism that helped identify discrepancies that could lead

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42807/psn-pdf
    February 17, 2015 - https://psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40718/psn-pdf
    August 31, 2011 - misinformation-medical-literature-what-role-do-error-and-fraud-play This commentary discusses how research errors, bias, and fraud lead

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35833/psn-pdf
    July 23, 2010 - the literature on medication administration errors and categorize systems and personnel issues that lead

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37851/psn-pdf
    June 18, 2008 - identification-and This article reviews how the complexity of care in the pediatric intensive care unit may lead

  7. Mutual Support: Severe Hypertension - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
    July 01, 2023 - She reasons that because dangerously elevated blood pressure can lead to stroke or seizures she needs

  8. Communication: Severe Hypertension - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
    July 01, 2023 - To avoid making assumptions that can lead to error, you should verify in writing or orally any nonverbal … looking at an electrocardiogram would quickly tell the nurse the severity of the situation and might lead

  9. Communication: Obstetric Hemorrhage - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
    July 01, 2023 - To avoid making assumptions that can lead to error, you should verify in writing or orally any nonverbal … looking at an electrocardiogram would quickly tell the nurse the severity of the situation and might lead

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865870/psn-pdf
    May 15, 2024 - Leading quality and safety on the frontline - a case study of department leaders in nursing homes. May 15, 2024 Magerøy M, Braut GS, Macrae C, et al. Leading quality and safety on the frontline - a case study of department leaders in nursing homes. J Healthc Leadersh. 2024;16:193-208. doi:10.2147/jhl.s454109. http…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73922/psn-pdf
    October 06, 2021 - Leading causes of anesthesia-related liability claims in ambulatory surgery centers. October 6, 2021 Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431. https://psnet.ahrq.go…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60986/psn-pdf
    January 01, 2021 - Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic. October 7, 2020 Gavin N, Romney M-LS, Lema PC, et al. Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic. BMJ Lea…

  13. Procedure Manual Section 7. Formulation of Task Force Recommendations | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-7-formulation-task-force-recommendations
    June 21, 2025 - In this case, the individual member or the primary topic lead speaks with the Chairs, requests a vote

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72637/psn-pdf
    January 13, 2021 - Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis. January 13, 2021 Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. Identifying Factors Leading to Harm in English G…

  15. Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category (pdf file)

    pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
    January 01, 2019 - Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category Page 1 of 9 Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854818/psn-pdf
    October 25, 2023 - The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. October 25, 2023 van Moll C, Egberts TCG, Wagner C, et al. The nature, causes, and clinical impact of errors in the clinical laboratory testing process lea…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866521/psn-pdf
    August 14, 2024 - High reliability in a safety net hospital leading to operational excellence. August 14, 2024 Didion L, Whitfield C, Bishop P, et al. High reliability in a safety net hospital leading to operational excellence. J Patient Saf. 2024;20(5):375-380. doi:10.1097/pts.0000000000001236. https://psnet.ahrq.gov/issue/high-re…

  18. The absence of a drug–disease interaction alert leads to a child's death. | PSNet

    psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
    July 08, 2015 - July 29, 2020 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

  19. High reliability in a safety net hospital leading to operational excellence. | PSNet

    psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence
    March 01, 2011 - September 28, 2022 The Collective Leadership for Safety Culture (Co-Lead) team intervention

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60191/psn-pdf
    April 01, 2020 - Unprofessional Behavior Leads to Complications. April 1, 2020 Unprofessional Behavior Leads to Complications. JN Learning. 2020. https://psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educa…
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