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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
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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
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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
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psnet.ahrq.gov/node/41060/psn-pdf
September 06, 2013 - flaws-clinical-reasoning-common-cause-diagnostic-error
Through an illustrative case report, this commentary describes how cognitive biases may lead
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psnet.ahrq.gov/node/36960/psn-pdf
September 12, 2011 - profiles-patient-safety-perfect-storm-emergency-department
The authors present a case of delayed diagnosis and discuss the cognitive dispositions that can lead
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - However, the error did lead to the performance of
additional blood tests (mostly activated partial thromboplastin … critical medication is unavailable,
this case illustrates how a seemingly safe substitution strategy can lead … With heparin, an overdose can lead to a stroke, or even death, especially in
vulnerable populations … Just like errors involving heparin, errors involving saline injection can lead to devastating outcomes
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psnet.ahrq.gov/node/45707/psn-pdf
April 18, 2018 - costs-and-consequences-associated-misdiagnosed-lower-extremity-cellulitis
Misdiagnosis is common and can lead
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_2-team-structure.pptx
July 01, 2023 - Therefore, as a Hospital AIM Team Lead you’ll want to understand all perceived losses and make it clear
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_2-team-structure.pptx
July 01, 2023 - Therefore, as a Hospital AIM Team Lead you’ll want to understand all perceived losses and make it clear
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psnet.ahrq.gov/node/38979/psn-pdf
October 14, 2009 - physicians are encouraged to ask questions, seek
feedback, and reflect on their experiences, could actually lead
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psnet.ahrq.gov/node/42799/psn-pdf
December 04, 2013 - automation can diminish human
performance, decision-making, and situational awareness—and thereby lead
-
psnet.ahrq.gov/node/43624/psn-pdf
October 22, 2014 - compendium-strategies-prevent-healthcare-associated-infections-acute-care-hospitals
https://psnet.ahrq.gov/issue/getting-doctors-clean-their-hands-lead-followers
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
July 01, 2023 - She reasons that because dangerously
elevated blood pressure can lead to stroke or seizures she needs
-
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…
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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…
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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…
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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…
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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
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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…
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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…