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101. Addressing intimate partner violence and helping to protect patients. | PSNet
     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.

102. 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

103. 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

104. 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

105. 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

106. 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

107. 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

108. Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment. | PSNet
     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 .

109. 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

110. Improving patient handovers from hospital to primary care: a systematic review. | PSNet
     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

111. Remembering to learn: the overlooked role of remembrance in safety improvement. | PSNet
     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

112. Positive deviance: a different approach to achieving patient safety. | PSNet
     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

113. Office-based anesthesia: safety and outcomes. | PSNet
     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

114. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
     January 01, 2023 - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading … can decrease the risk of leaks around cuffs. 3 UNDER PRESSURE: TRACHEOSTOMY CUFF OVER INFLATION LEADING … this could happen, the patient developed increasing hypoxemia and respiratory distress, ultimately leading … to an appropriate rehabilitation facility. 7 UNDER PRESSURE: TRACHEOSTOMY CUFF OVER INFLATION LEADING … was to insert air repeatedly into the cuff, but increased balloon pressure led to tissue necrosis, leading

115. Systems analysis of adverse drug events. | PSNet
     psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
     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

116. Leadership: an effective human factor during COVID-19. | PSNet
     psnet.ahrq.gov/issue/leadership-effective-human-factor-during-covid-19
     March 31, 2021 - July 28, 2021 Organisational crisis resource management: leading an academic department … November 25, 2020 Organisational crisis resource management: leading an academic department

117. US emergency department visits attributed to medication harms, 2017-2019. | PSNet
     psnet.ahrq.gov/issue/us-emergency-department-visits-attributed-medication-harms-2017-2019
     December 15, 2021 - December 15, 2021 Medication use leading to emergency department visits for adverse drug … December 16, 2020 National estimates of insulin-related hypoglycemia and errors leading

118. Debriefing in the emergency department after clinical events: a practical guide. | PSNet
     psnet.ahrq.gov/issue/debriefing-emergency-department-after-clinical-events-practical-guide
     November 16, 2022 - August 10, 2022 Organisational crisis resource management: leading an academic department … Related Resources WebM&M Cases Misconnection Leading

119. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet
     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

120. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? | PSNet
     psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety
     October 23, 2013 - ) is a process frequently employed by health care institutions to understand the sequence of events leading … lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading