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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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psnet.ahrq.gov/node/42119/psn-pdf
January 24, 2019 - encapsulates lessons from reviews of patient safety strategies and emphasizes physicians'
roles in leading
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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
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psnet.ahrq.gov/node/72665/psn-pdf
January 20, 2021 - This article reviews the scope of the problem,
factors leading to disruptive physicians, consequences
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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
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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.
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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.
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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
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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
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psnet.ahrq.gov/issue/congress-healthcare-leadership
December 18, 2019 - Linkedin
Email
Print
Health executives have a primary role in leading
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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