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61. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73895/psn-pdf
    September 29, 2021 - Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of … https://psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead … https://psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-flood-correction … https://psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-flood-correction

62. FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved. | PSNet
    psnet.ahrq.gov/issue/fda-drug-safety-communication-fda-cautions-about-dosing-errors-when-switching-between
    April 08, 2020 - announcement alerts prescribers to differences in two oral formulations of the same medication that can lead … Differences in strength expression on product labels of compounders and conventional manufacturers may lead … Differences in strength expression on product labels of compounders and conventional manufacturers may lead

63. Slide 1 (pdf file)
    effectivehealthcare.ahrq.gov/sites/default/files/ahrq_community_forum_webinar_bonoff.pdf
    January 01, 2000 - for success • Methods to support patient and consumer involvement are evolving – NBCC Project LEAD … opportunities – Reduce barriers to participation Advocacy Training: The NBCC Project LEAD … ® Story What is Project LEAD®? … Continuing Education, mentoring Types of Project LEAD Courses • Project LEAD® Institute- an … ® Courses • Project LEAD® Workshop – introductory level course on basic scientific concepts and

64. Training and Support for Patients and Consumers Engaged in Research (pdf file)
    effectivehealthcare.ahrq.gov/sites/default/files/bonoff-text.pdf
    January 01, 2000 - element for success § Methods to support patient and consumer involvement are evolving § NBCC Project LEAD … ® Story Slide 8 What is Project LEAD®? … range of NBCC research advocacy and public policy training § Includes: § Full range of Project LEAD … sessions § Mentoring § Over 2000 graduates, 74 courses – since 1995 Slide 11 Types of Project LEAD … Courses § Project LEAD® Institute- an intensive science and research methodology course to prepare

65. Miscommunication in the OR Leads to Anticoagulation Mishap | PSNet
    psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
    May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…

66. Misconnection Leading to Arterial Thrombosis | PSNet
    psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…

67. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41800/psn-pdf
    November 07, 2012 - The effects of electrode misplacement on clinicians' interpretation of the standard 12-lead electrocardiogram … The effects of electrode misplacement on clinicians' interpretation of the standard 12-lead electrocardiogram … https://psnet.ahrq.gov/issue/effects-electrode-misplacement-clinicians-interpretation-standard-12-lead … - electrocardiogram Misplacement of the electrical leads when performing a standard 12-lead electrocardiogram … https://psnet.ahrq.gov/issue/effects-electrode-misplacement-clinicians-interpretation-standard-12-lead-electrocardiogram

68. Module 2—The Infection Preventionist—The Nursing Home Infection Preventionist Training Course | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/module-2-infection-preventionist.html
    May 01, 2022 - Preventionist Training Course This module describes the role of an infection preventionist, who serves as the lead

69. Administering a saline flush "site unseen" can lead to a wrong route error. | PSNet
    psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
    June 10, 2018 - Newspaper/Magazine Article Administering a saline flush "site unseen" can lead to … Citation Text: Administering a saline flush "site unseen" can lead to a wrong route error. … Cite Citation Citation Text: Administering a saline flush "site unseen" can lead … June 10, 2018 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

70. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - Each Impact Case Study must meet basic criteria to move beyond the lead stage.

71. Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests? | PSNet
    psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-flood-correction
    March 27, 2024 - Open Notes shines light on errors in patient medical records — will the new rule lead … Citation Text: Open Notes shines light on errors in patient medical records — will the new rule lead … Citation Text: Open Notes shines light on errors in patient medical records — will the new rule lead

72. Candor-Impguide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/candor-impguide.pdf
    April 01, 2016 - Care for the Caregiver Lead Resolution Team Lead Disclosure Lead CANDOR Implementation Team … The CANDOR Implementation Team should have three subgroups with a Team Lead for each subgroup. … The Disclosure Team Lead is responsible for implementing the disclosure communication process in the … The Care for the Caregiver Team Lead is responsible for implementing a Care for the Caregiver program … Lead Care for the Caregiver Team Lead Event Reporting, Investigation, and Analysis Team Lead

73. The other opioid crisis: hospital shortages lead to patient pain, medical errors. | PSNet
    psnet.ahrq.gov/issue/other-opioid-crisis-hospital-shortages-lead-patient-pain-medical-errors
    April 08, 2020 - Newspaper/Magazine Article The other opioid crisis: hospital shortages lead to patient … Citation Text: The other opioid crisis: hospital shortages lead to patient pain, medical errors. … Cite Citation Citation Text: The other opioid crisis: hospital shortages lead

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47735/psn-pdf
    June 24, 2019 - The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety … https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead- … https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-way-patient-safety … https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-way-patient-safety

75. Implementing Opioid Risk Screening for Older Adults Using Automated Patient Reminders in an Electronic Health Record Case Study (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-risk-screening.pdf
    June 02, 2025 - The physician- owner, who also acts as a quality improvement (QI) lead at Pearl Family Medicine, recognized … The physician-owner/QI lead opted to screen with existing, validated screening tools available for … The Pearl team, the physician-owner/QI lead and office manager, planned and implemented an intervention … 1 PA1 ▶ Number of patients: 1,200 ▶ Quality Improvement team: The (MD) practice owner was the QI Lead … The physician-owner/QI lead at Pearl Family Medicine felt a professional obligation to make improvements

76. Geographicinfoib (pdf file)
    hcup-us.ahrq.gov/reports/race/GeographicInfoIB.pdf
    April 01, 2011 - incidence of lead poisoning. … “Lead Poisoning Maps in Rhode Island Reveal Huge Disparities, Guide Cleanup,” ScienceDaily. … Lead Poisoning Map Shows Huge Disparities in Rate of Affliction,” Providence Business News. … For more information, visit the Childhood Lead Action Project. … /RI-lead-poisoning-map-shows-huge-disparities-in-affliction,53511 http://www.pbn.com/RI-lead-poisoning-map-shows-huge-disparities-in-affliction

77. 017-Ss-Importance-Ssi-Mrsa-Prevention-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/017-ss-importance-ssi-mrsa-prevention-fg.docx
    April 01, 2025 - Slide 10 MRSA and SSIs Lead to Increased Mortality SAY: Among surgical patients, SSIs are associated … Slide 11 MRSA and SSIs Lead to Increased Costs SAY: Overall, it is estimated that SSIs account for … In addition to the increased length of stay, SSIs also lead to increased cost of care. … A person’s own MRSA colonization can lead to invasive disease and/or an SSI. … Surgical procedures and underlying illnesses decrease or bypass patients’ natural defenses and can lead

78. Career impact of the chief resident in quality and safety training program: an alumni evaluation | PSNet
    psnet.ahrq.gov/issue/career-impact-chief-resident-quality-and-safety-training-program-alumni-evaluation
    June 19, 2019 - Resident in Quality and Safety (CRQS) program alumni suggests that such programs can teach residents to lead … and engage other residents in patient safety and ultimately lead to a workforce fostering a culture … February 24, 2011 Did duty hour reform lead to better outcomes among the highest risk

79. Module 8: Organizational Learning and Sustainability | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
    August 01, 2022 - The Implementation Team Lead and other Team Leads help build and promote a shared vision of organizational … Many models in the literature define the steps of change that lead to a sustainable improvement. … The CANDOR Implementation Team Lead not only explains the program goals and components, but also helps … The organization can support the CANDOR Implementation Team Lead and other champions by providing ongoing … The CANDOR Implementation Team Lead and Team Leads play an important role in ensuring that frontline

80. Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. | PSNet
    psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors
    June 10, 2018 - Article Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead … Citation Text: Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to … Citation Citation Text: Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead … Interruptions lead to errors and unfinished…wait, what was I doing?