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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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.

  9. 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

  10. 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

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42119/psn-pdf
    January 24, 2019 - encapsulates lessons from  reviews of patient safety strategies and emphasizes physicians' roles in leading

  12. 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

  13. 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

  14. 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

  15. 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.

  16. 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.

  17. Computer entry errors. | PSNet

    psnet.ahrq.gov/issue/computer-entry-errors
    March 06, 2005 - involving the incomplete or incorrect entry of medication information into a computer, were the fourth leading

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60928/psn-pdf
    September 16, 2020 - dangers-ignoring-beers-criteria-prescribing-cascade https://psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults

  19. Congress on Healthcare Leadership | PSNet

    psnet.ahrq.gov/issue/congress-healthcare-leadership
    December 18, 2019 - Linkedin Email Print Health executives have a primary role in leading

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847735/psn-pdf
    May 30, 2023 - psnet.ahrq.gov/issue/sops-ambulatory-surgery-center-survey-what-you-need-know https://psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers
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