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81. Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. | PSNet
    psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy-postanesthesia-care-unit
    June 10, 2018 - Newspaper/Magazine Article Drawn curtains, muted alarms, and diverted attention lead … Citation Text: Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia … Citation Citation Text: Drawn curtains, muted alarms, and diverted attention lead … May 7, 2014 Administering a saline flush "site unseen" can lead to a wrong route error

82. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-slides.pptx
    June 01, 2021 - Understanding the science of safety Improve teamwork and communication Recognize current practices that may lead … Cambridge University Press Identifying Targets 12 13 The antibiotic stewardship team Physician lead … Pharmacist lead Nurse lead Prioritize top problems Identify all the factors that could lead to this

83. Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing? | PSNet
    psnet.ahrq.gov/issue/side-tracks-safety-express-interruptions-lead-errors-and-unfinishedwait-what-was-i-doing
    June 10, 2018 - Interruptions lead to errors and unfinished…wait, what was I doing? … Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! … Interruptions lead to errors and unfinished…wait, what was I doing? ISMP Medication Safety Alert! … 8, 2016 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead

84. Quality and patient safety. Engaging your board to take the lead.  | PSNet
    psnet.ahrq.gov/issue/quality-and-patient-safety-engaging-your-board-take-lead
    April 21, 2015 - Engaging your board to take the lead.  Citation Text: Bader BS. … Engaging your board to take the lead. Healthcare executive. 2006;21(2):64, 66-7. … Engaging your board to take the lead. Healthcare executive. 2006;21(2):64, 66-7.

85. Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors. | PSNet
    psnet.ahrq.gov/issue/differences-strength-expression-product-labels-compounders-and-conventional-manufacturers-may
    April 08, 2020 - 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 … Differences in strength expression on product labels of compounders and conventional manufacturers may lead

86. New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors. | PSNet
    psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors
    April 26, 2023 - Doctors worry that could lead to errors. … Doctors worry that could lead to errors. Lovelace Jr, B. NBC News. September 7, 2022. … Doctors worry that could lead to errors. Lovelace Jr, B. NBC News. September 7, 2022.

87. PCIP Provider Qualitative Interview Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-staff-ny.pdf
    June 02, 2025 - - - - - - - - - - - - - - - - - - - - - - - - HealthyHearts NYC Provider/Quality Improvement Team Lead … How long have you been the/a lead clinician at this practice? 2. … HealthyHearts NYC Provider/Quality Improvement Team Lead … HealthyHearts NYC Provider/Quality Improvement Team Lead … 4 HealthyHearts NYC Provider/Quality Improvement Team Lead (CHCANYS

88. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41436/psn-pdf
    October 19, 2012 - Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment … Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment … https://psnet.ahrq.gov/issue/which-clinical-errors-lead-referral-uk-paediatricians-national-clinical- … https://psnet.ahrq.gov/issue/which-clinical-errors-lead-referral-uk-paediatricians-national-clinical-assessment-service … https://psnet.ahrq.gov/issue/which-clinical-errors-lead-referral-uk-paediatricians-national-clinical-assessment-service

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73151/psn-pdf
    April 14, 2021 - Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics? … https://psnet.ahrq.gov/issue/could-efforts-fight-coronavirus-lead-overuse-antibiotics Antibiotic overuse … https://psnet.ahrq.gov/issue/could-efforts-fight-coronavirus-lead-overuse-antibiotics https://psnet.ahrq.gov

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836869/psn-pdf
    April 06, 2022 - Will prosecuting medical errors lead to a culture of silence? April 6, 2022 Fiore K. … https://psnet.ahrq.gov/issue/will-prosecuting-medical-errors-lead-culture-silence Experts are concerned … https://psnet.ahrq.gov/issue/will-prosecuting-medical-errors-lead-culture-silence https://psnet.ahrq.gov

91. Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable moment. | PSNet
    psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment
    September 29, 2017 - Commentary Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable … Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A Teachable Moment. … Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A Teachable Moment. … July 29, 2020 Does increased schedule flexibility lead to change?

92. Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Introduction (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/01-sops-riverside-handoffs-webcast-intro.pdf
    October 30, 2024 - Lead Research Associate and Communications Lead User Network for AHRQ Surveys on Patient Safety Culture

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44118/psn-pdf
    May 19, 2018 - Inadequate preoperative team briefings lead to more intraoperative adverse events. … Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. … https://psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse- … https://psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse-events … https://psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse-events

94. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/838141/psn-pdf
    September 21, 2022 - Doctors worry that could lead to errors. September 21, 2022 Lovelace Jr, B. NBC News. … https://psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors Look-alike … https://psnet.ahrq.gov/issue/new-covid-boosters-look-lot-old-ones-doctors-worry-could-lead-errors https

95. Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional development, system improvements, clinician engagement, and enhanced patient safety culture? | PSNet
    psnet.ahrq.gov/issue/systematic-review-morbidity-and-mortality-meeting-standardization-does-it-lead-improved
    October 23, 2024 - Review Systematic review of morbidity and mortality meeting standardization: does it lead … Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional … Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional

96. Six Building Blocks How-To-Implement Toolkit: Prepare and Launch Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-prepare.pdf
    February 18, 2021 - clinical voice on the team Tracking and monitoring lead Highly variable depending on your system … Agenda (details) Use what you learned during the preparatory work to lead the opioid improvement team … Based on existing capacity, the QI lead and the tracking and monitoring lead should propose an approach … lead 25 minutes Clinical champion 5 minutes When planning the clinicwide kickoff, lead the team … (you): Tracking and Monitoring Lead: Clinical Champion: How To Do It 1.

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46103/psn-pdf
    September 23, 2017 - Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable moment. … Polypharmacy in the Elderly-When Good Drugs Lead to Bad Outcomes: A Teachable Moment. … https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable- moment … https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment … https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment

98. Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. | PSNet
    psnet.ahrq.gov/issue/codeine-use-certain-children-after-tonsillectomy-andor-adenoidectomy-may-lead-rare-life
    August 20, 2021 - Resource Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead … Citation Text: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to … Citation Citation Text: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead

99. The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety. | PSNet
    psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-way-patient-safety
    April 03, 2019 - Report The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead … Citation Text: The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the … Citation Citation Text: The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead

100. Heart Healthy Ohio Initiative Charter: August 2021 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/57-ohio-hhoi-charter.pdf
     August 01, 2021 - Lead: Aleece Caron, PhD The HHOI Data and Evaluation Team will develop and evaluate success metrics … Interim Lead: Cathy Sullivan, MS, RD The HHOI Dissemination, Engagement, and Sustainability Team will … PI Bolen, Cardi-OH lead, with PI Caron has used QI practice facilitation, audit and feedback, performance … , MS (CWRU) Research Assistant, TBD HHOI Data and Evaluation Team Thomas Love, PhD (CWRU) Co- Lead … Adam Perzynski, PhD (CWRU) Co-Lead Douglas Einstadter, MD, MPH (CWRU) Kurt Stange, MD, PhD (CWRU)