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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34690/psn-pdf
    February 10, 2011 - They found the leading cause of error was lack of drug knowledge on the part of the ordering physician … Overall, the authors describe 16 system failures leading to ADEs, with seven accounting for 78% of all
  2. psnet.ahrq.gov/issue/medical-diagnoses-commonly-associated-pediatric-malpractice-lawsuits-united-states
    November 16, 2022 - Analysis of closed malpractice claims has been used to identify patterns of errors and system problems leading … of data from the Physicians Insurers Association of America focuses on specific pediatric diagnoses leading
  3. psnet.ahrq.gov/issue/emergency-department-visits-antibiotic-associated-adverse-events
    October 31, 2014 - February 2, 2011 National estimates of insulin-related hypoglycemia and errors leading … December 18, 2014 Medication use leading to emergency department visits for adverse drug … October 16, 2012 Medication use leading to emergency department visits for adverse drug
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44951/psn-pdf
    March 02, 2016 - using-targeted-solutions-toolr-improve-emergency-department-handoffs- community-hospital Despite extensive research, handoffs remain a leading … dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37586/psn-pdf
    March 05, 2008 - national-surveillance-emergency-department-visits-outpatient-adverse-drug- events-children-and Medication misadventures leading … medication-misadventures-resulting-emergency-department-visits-hmo-medical-center https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37531/psn-pdf
    February 22, 2011 - accurately gauging illness severity and formulating an appropriate plan of action may be difficult, leading … Most cases alleged that clinicians failed to accurately diagnose the patient; types of errors leading
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38291/psn-pdf
    April 08, 2011 - Analysis of closed malpractice claims has been used to identify patterns of errors and system problems leading … of data from the Physicians Insurers Association of America focuses on specific pediatric diagnoses leading
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44601/psn-pdf
    February 23, 2018 - psnet.ahrq.gov/issue/patient-safety-emergency-medicine https://psnet.ahrq.gov/issue/medication-overdoses-leading-emergency-department-visits-among-children … https://psnet.ahrq.gov/issue/medication-overdoses-leading-emergency-department-visits-among-children
  9. psnet.ahrq.gov/issue/addressing-intimate-partner-violence-and-helping-protect-patients
    February 15, 2023 - Citation Related Resources From the Same Author(s) Mental health conditions leading … July 17, 2024 Mental health conditions leading cause of pregnancy-related deaths.
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28 … Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. … https://psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis … this could happen, the patient developed increasing hypoxemia and respiratory distress, ultimately leading … On inspection, the tracheal cuff had burst, leading to a severe leak in addition to a tracheal tear with
  11. psnet.ahrq.gov/issue/assessing-bedside-bar-coding-readiness
    December 19, 2018 - Copy Citation Related Resources From the Same Author(s) Leading a Strategic … February 6, 2019 Leading a Strategic Planning Effort.
  12. psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
    October 03, 2012 - While reviewing the details of the case, the author explores the pitfalls leading to missed diagnoses … March 20, 2013 Medication use leading to emergency department visits for adverse drug
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45595/psn-pdf
    April 19, 2017 - estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters A recent article asserted that medical error is the third leading … estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us
  14. psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
    January 09, 2019 - patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading … January 9, 2019 New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - Creating a culture of safety requires leading differently. … Evidence suggests this process is effective for leading organizational change.(6) It also models a learning … Leading through partnership means understanding that no amount of time, interest, information, and skill … Leading change: why transformation efforts fail. Harv Bus Rev. 1995;73:59-67. [Available at] 8. … )26001-4 https://psnet.ahrq.gov//#ref6back https://psnet.ahrq.gov//#ref7back http://hbr.org/1995/05/leading-change-why-transformation-efforts-fail
  16. psnet.ahrq.gov/issue/causes-death-residents-acgme-accredited-programs-2000-through-2014-implications-learning
    January 31, 2018 - This retrospective cohort study found that the leading cause of death among resident physicians is cancer … , and the second leading cause of death is suicide .
  17. psnet.ahrq.gov/issue/remembering-learn-overlooked-role-remembrance-safety-improvement
    February 28, 2024 - February 28, 2024 Leading quality and safety on the frontline - a case study of department … improvement and patient safety education with clinical care October 2, 2019 Effectively leading
  18. psnet.ahrq.gov/issue/positive-deviance-different-approach-achieving-patient-safety
    May 15, 2024 - RIS Download Citation Related Resources From the Same Author(s) Leading … August 13, 2013 Leading clinical handover improvement: a change strategy to implement
  19. psnet.ahrq.gov/issue/office-based-anesthesia-safety-and-outcomes
    February 18, 2019 - February 18, 2019 Leading causes of anesthesia-related liability claims in ambulatory … January 4, 2012 Epidural pump programming error leading to inadvertent 10-fold dosing
  20. psnet.ahrq.gov/issue/improving-patient-handovers-hospital-primary-care-systematic-review
    March 06, 2013 - Care transitions remain a particularly vulnerable time for patient safety, leading to an increasing … December 5, 2012 Medication use leading to emergency department visits for adverse drug

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