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141. Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors. | PSNet
     psnet.ahrq.gov/issue/utilization-seniors-falls-investigation-methodology-identify-system-wide-causes-falls
     November 21, 2014 - therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading … December 15, 2021 System issues leading to "found-on-floor" incidents: a multi-incident

142. 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

143. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48106/psn-pdf
     July 24, 2019 - issue/teamwork-toolkit https://psnet.ahrq.gov/primer/teamwork-training https://psnet.ahrq.gov/issue/leading-article-how-can-i-optimise-my-role-leader-within-surgical-team

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60944/psn-pdf
     September 23, 2020 - science has played during the COVID-19 pandemic, defined as the loosening of methodological standards leading

145. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852806/psn-pdf
     February 24, 2025 - medias-role-patient-safety https://psnet.ahrq.gov/issue/dying-care https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should-question

146. Dissecting the Presentation | PSNet
     psnet.ahrq.gov/web-mm/dissecting-presentation
     May 05, 2021 - List three factors leading to a missed diagnosis of aortic dissection. … The dissection was probably present on admission and the tear in the aorta had impaired blood flow leading … Factors Leading to Missed Diagnosis of Aortic Dissection The diagnosis of aortic dissection in the emergency … A second factor leading to misdiagnosis was clinical symptoms and laboratory findings that suggested … Factors leading to failure to diagnose acute aortic dissection in the emergency room.

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73668/psn-pdf
     September 01, 2021 - safe-day-call-reducing-silos-health-care-through-frontline-risk-assessment https://psnet.ahrq.gov/issue/leading-article-how-can-i-optimise-my-role-leader-within-surgical-team

148. 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

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866957/psn-pdf
     October 16, 2024 - pharmacy-prevalence-second-victim-syndrome-comprehensive-cancer-center Adverse events can negatively impact a provider's mental and physical health, leading

150. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74093/psn-pdf
     November 17, 2021 - prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism

151. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47669/psn-pdf
     July 17, 2019 - decision support, the usability of the tool and fit with the critical care environment were suboptimal, leading

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73631/psn-pdf
     August 25, 2021 - This narrative review of 75 studies concluded that cardiovascular medications are a leading cause of

153. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/848754
     January 01, 2025 - Healthcare Research and Quality Implementation of Patient Safety Projects Curated Library Foundations Leading … lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading … lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading … Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev  1995;73(2);59-67. … https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail https://psnet.ahrq.gov/issue

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48175/psn-pdf
     August 07, 2019 - psnet.ahrq.gov/issue/strengthening-medical-error-meme-pool https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72511/psn-pdf
     November 25, 2020 - hospital-preparedness-covid-19-surge-assessment-tool https://psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine

156. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837155/psn-pdf
     November 15, 2022 - advancing-diagnostic-excellence-older-adults-proceedings-workshop-brief https://psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults

157. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47850/psn-pdf
     March 27, 2019 - psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866519/psn-pdf
     August 14, 2024 - a medication error in the ED, with about 43% of these errors being potentially harmful but without leading

159. Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. | PSNet
     psnet.ahrq.gov/issue/older-patients-understanding-emergency-department-discharge-information-and-its-relationship
     October 10, 2012 - August 4, 2021 Cascade iatrogenesis: factors leading to the development of adverse events … May 25, 2011 Medication overdoses leading to emergency department visits among children

160. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
     psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
     May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer … initiatives, medical errors still occur frequently in these situations (with these errors sometimes leading