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1181. When We Do Harm: A Doctor Confronts Medical Error. | PSNet
      psnet.ahrq.gov/issue/when-we-do-harm-doctor-confronts-medical-error
      July 24, 2018 - WebM&M Cases Failure to Adhere to Dietary Restrictions Leading

1182. Nurses' role in detecting deterioration in ward patients: systematic literature review. | PSNet
      psnet.ahrq.gov/issue/nurses-role-detecting-deterioration-ward-patients-systematic-literature-review
      March 27, 2018 - August 4, 2010 Leading successful rapid response teams: a multisite implementation evaluation

1183. Gap assessment of hospitals' adoption of the just culture principles. | PSNet
      psnet.ahrq.gov/issue/gap-assessment-hospitals-adoption-just-culture-principles
      September 21, 2005 - February 13, 2019 Leading a highly visible hospital through a serious reportable event

1184. Quality Improvement Series. | PSNet
      psnet.ahrq.gov/issue/quality-improvement-series
      July 05, 2013 - November 15, 2017 Effectively leading for quality.

1185. Misleading Complaint | PSNet
      psnet.ahrq.gov/web-mm/misleading-complaint
      December 01, 2009 - The ED physician relied heavily on this documented triage complaint, leading to an overly focused history … This case exemplifies how multiple latent factors embedded in triage can initiate a cascade of events leading … Multiple latent factors embedded in triage can initiate a cascade of events leading to a diagnostic error

1186. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33689/psn-pdf
      October 01, 2009 - Perhaps the two biggest were those leading to the deaths of Libby Zion in New York Hospital in 1984 … amputated University Community Hospital, Tampa, FL 1995 New focus on wrong-site surgery, ultimately leading … dehydration Johns Hopkins Hospital 2001 Josie's parents form an alliance with Johns Hopkins' leadership (leading

1187. Hazards of Loading Doses | PSNet
      psnet.ahrq.gov/web-mm/hazards-loading-doses
      December 01, 2003 - Phenytoin was listed as the fourth leading drug associated with loading dose incidents, behind only warfarin … WebM&M Cases Failure to Adhere to Dietary Restrictions Leading … July 31, 2023 WebM&M Cases Misconnection Leading

1188. Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections. | PSNet
      psnet.ahrq.gov/issue/partnering-heal-teaming-against-healthcare-associated-infections
      November 16, 2011 - November 16, 2011 New HHS Data Shows Major Strides Made in Patient Safety, Leading to

1189. Pathways for Patient Safety. | PSNet
      psnet.ahrq.gov/issue/pathways-patient-safety
      May 06, 2015 - Information Pathway for Medication Safety: Leading a Strategic Planning Effort (PDF)

1190. People, processes, health IT and accurate patient identification. | PSNet
      psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
      April 11, 2018 - June 17, 2020 Mental health conditions leading cause of pregnancy-related deaths.

1191. Second Victim: Error, Guilt, Trauma, and Resilience. | PSNet
      psnet.ahrq.gov/issue/second-victim-error-guilt-trauma-and-resilience
      April 13, 2018 - April 12, 2017 Leading Health Care Transformation: A Primer for Clinical Leaders.

1192. Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients. | PSNet
      psnet.ahrq.gov/issue/eliminating-racial-and-ethnic-disparities-causing-mortality-and-morbidity-pregnant-and
      December 23, 2016 - February 15, 2023 Mental health conditions leading cause of pregnancy-related deaths.

1193. Navigating risks in breast cancer diagnosis and treatment. | PSNet
      psnet.ahrq.gov/issue/navigating-risks-breast-cancer-diagnosis-and-treatment
      December 19, 2012 - November 17, 2009 Leading causes of anesthesia-related liability claims in ambulatory

1194. Strategies for Creating, Sustaining, and Improving a Culture of Safety in Health Care, Second Edition. | PSNet
      psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-second-edition
      May 20, 2015 - April 22, 2018 Leading a Culture of Safety: a Blueprint for Success.

1195. Patient Safety: Investigating and Reporting Serious Clinical Incidents. | PSNet
      psnet.ahrq.gov/issue/patient-safety-investigating-and-reporting-serious-clinical-incidents
      November 10, 2017 - April 12, 2017 Leading Health Care Transformation: A Primer for Clinical Leaders.

1196. Foundations of Safety Science: a century of understanding accidents and disasters. | PSNet
      psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters
      October 05, 2011 - August 24, 2017 Leading Health Care Transformation: A Primer for Clinical Leaders.

1197. Are we finally getting serious about medical errors? | PSNet
      psnet.ahrq.gov/issue/are-we-finally-getting-serious-about-medical-errors
      May 11, 2016 - February 11, 2015 System issues leading to "found-on-floor" incidents: a multi-incident

1198. Promote a culture of safety with good catch reports. | PSNet
      psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports
      November 06, 2015 - July 18, 2018 Why are medical errors still a leading cause of death?

1199. Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development. | PSNet
      psnet.ahrq.gov/issue/healthcare-quality-and-safety-workforce-report-new-imperatives-quality-and-safety-mean-new
      May 06, 2015 - September 3, 2024 Leading a Culture of Safety: a Blueprint for Success.

1200. ISMP updates its list of drug name pairs with Tall man letters. | PSNet
      psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
      June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading