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121. Lessons from Event Reports. | PSNet
     psnet.ahrq.gov/issue/lessons-event-reports
     January 16, 2025 - Small successes can inform and motivate actions leading to sustainable, evidence-based change .

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73456/psn-pdf
     June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 … Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. … https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe … https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia … https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia

123. Using video to assess and improve patient safety during simulated and actual neonatal resuscitation. | PSNet
     psnet.ahrq.gov/issue/using-video-assess-and-improve-patient-safety-during-simulated-and-actual-neonatal
     July 29, 2020 - therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading … December 12, 2012 Mistaken identity of skin cleansing solution leading to extensive chemical

124. Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry. | PSNet
     psnet.ahrq.gov/issue/interventional-procedures-outside-operating-room-results-national-anesthesia-clinical
     March 06, 2019 - October 19, 2022 Leading causes of anesthesia-related liability claims in ambulatory … 2021 WebM&M Cases Inadequate Anesthesia Preparation Leading

125. Rethinking Patient Safety. | PSNet
     psnet.ahrq.gov/issue/rethinking-patient-safety
     April 13, 2018 - April 17, 2018 Leading High-Reliability Organizations in Healthcare. … June 14, 2017 Leading a Culture of Safety: a Blueprint for Success.

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867769/psn-pdf
     March 12, 2025 - https://psnet.ahrq.gov/issue/lessons-event-reports Small successes can inform and motivate actions leading

127. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37162/psn-pdf
     June 16, 2019 - insulin being administered instead of heparin and discusses issues of software and staff unawareness leading

128. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
     April 01, 2015 - normal chest radiograph should not be used to rule out acute aortic dissection List three factors leading … The dissection was probably present on admission and the tear in the aorta had impaired blood flow leading … on how or whether this finding should have influenced the clinicians in this case * * Factors Leading … Factors leading to failure to diagnose acute aortic dissection in the emergency room. … Am J Emerg Med. 2012;30:1622-1626. http://www.ncbi.nlm.nih.gov/pubmed/22306397 * Factors Leading

129. Continuing Education | PSNet
     psnet.ahrq.gov/continuing-education
     February 26, 2025 - Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation … However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition … suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations … prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading

130. Reconciliation failures lead to medication errors. | PSNet
     psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
     November 01, 2012 - potential error, intercepted error), types of errors (eg, improper dose, wrong drug, wrong time), and leading

131. What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior? | PSNet
     psnet.ahrq.gov/issue/what-evidence-supports-use-computerized-alerts-and-prompts-improve-clinicians-prescribing
     August 04, 2021 - interactions for use in electronic health records systems with computerized physician order entry: review of leading … interactions for use in electronic health records systems with computerized physician order entry: review of leading

132. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition. | PSNet
     psnet.ahrq.gov/issue/lean-hospitals-improving-quality-patient-safety-and-employee-engagement-third-edition
     May 04, 2016 - Copy Citation Related Resources From the Same Author(s) Leading High-Reliability … May 21, 2019 Leading Health Care Transformation: A Primer for Clinical Leaders.

133. Engineering Patient Safety in Radiation Oncology: University of North Carolina's Pursuit for High Reliability and Value Creation. | PSNet
     psnet.ahrq.gov/issue/engineering-patient-safety-radiation-oncology-university-north-carolinas-pursuit-high
     May 04, 2016 - Copy Citation Related Resources From the Same Author(s) Leading High-Reliability … April 12, 2017 Leading Health Care Transformation: A Primer for Clinical Leaders.

134. ISMP medication error report analysis. | PSNet
     psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-16
     June 16, 2019 - insulin being administered instead of heparin and discusses issues of software and staff unawareness leading

135. The Shift Coupon: an innovative method to monitor adverse events. | PSNet
     psnet.ahrq.gov/issue/shift-coupon-innovative-method-monitor-adverse-events
     June 25, 2010 - June 25, 2010 Medication use leading to emergency department visits for adverse drug … therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading

136. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74195/psn-pdf
     December 15, 2021 - https://psnet.ahrq.gov/issue/technology-education-and-safety-0 https://psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72665/psn-pdf
     January 20, 2021 - This article reviews the scope of the problem,  factors leading to disruptive physicians, consequences

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73099/psn-pdf
     March 31, 2021 - supporting-nurses-essential-partners-diagnosis https://psnet.ahrq.gov/issue/new-diagnostic-team https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health

139. Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use | PSNet
     psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
     September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading … The HomeMeds Medication Safety Program identified and addressed targeted medication problems, leading … implementation identified and addressed several common medication problems found among older adults, leading

140. Emergency department visits for antibiotic-associated adverse events. | PSNet
     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