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181. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866588/psn-pdf
     August 28, 2024 - impact-hindsight-bias-diagnosis-perioperative-events-anesthesia-providers- multicenter Hindsight bias refers to the tendency to judge events leading

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866156/psn-pdf
     June 20, 2024 - interventions-prevent-falls-older-adults-updated-evidence-report-and- systematic-review-us Falls are a leading

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60053/psn-pdf
     January 01, 2021 - RCA revealed that primary contributory factors leading to adverse events were knowledge/educational

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74842/psn-pdf
     February 16, 2022 - initiative-reduce-insulin-related-adverse-drug-events-childrens-hospital https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836823/psn-pdf
     March 30, 2022 - ://psnet.ahrq.gov/primer/checklists https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61100/psn-pdf
     November 04, 2020 - patient-errors-use-injectable-antidiabetic-medications-need-improved-clinic-based-education https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department

187. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74857/psn-pdf
     February 23, 2022 - clinical-reasoning-dire-times-analysis-cognitive-biases-clinical-cases-during- covid-19 The uncertainty and pressure of the COVID-19 pandemic can introduce cognitive biases leading

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73171/psn-pdf
     April 21, 2021 - ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety https://psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841472/psn-pdf
     December 14, 2022 - reducing-potential-errors-associated-insulin-administration-integrative-review https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department

190. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60201/psn-pdf
     April 08, 2020 - differently with patients, communities, interprofessional teams, health care systems, and societies, leading

191. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838181/psn-pdf
     September 28, 2022 - factors-associated-potentially-harmful-medication-prescribing-nursing-homes-scoping-review https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

192. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72625/psn-pdf
     January 13, 2021 - special-edition-perspective-technology-responses-covid-19 https://psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine

193. WebM&M: Case Studies | PSNet
     psnet.ahrq.gov/webmm-case-studies
     March 25, 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 … weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading

194. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. | PSNet
     psnet.ahrq.gov/issue/incidence-and-types-preventable-adverse-events-elderly-patients-population-based-review
     June 23, 2015 - February 18, 2011 Leading article: how can I optimise my role as a leader within the … therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading

195. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37421/psn-pdf
     February 15, 2011 - observation to determine the incidence of prescribing errors in a retail pharmacy and explore the factors leading

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35033/psn-pdf
     May 18, 2005 - medical-errors-still-claiming-many-lives This article highlights a commentary published in JAMA by two leading

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/862600/psn-pdf
     February 14, 2024 - fatigue occurs when clinical decision support systems (CDSS) produce numerous low-relevance alerts, leading

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864373/psn-pdf
     March 13, 2024 - situ-simulation-quality-improvement-tool-identify-and-mitigate-latent-safety-threats https://psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49729/psn-pdf
     April 01, 2015 - 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 … A second factor leading to misdiagnosis was clinical symptoms and laboratory findings that suggested … Extension of the aortic dissection downwards to involve the mesenteric artery leading to mesenteric … Factors leading to failure to diagnose acute aortic dissection in the emergency room.

200. Technical Expert Panel | PSNet
     psnet.ahrq.gov/Information/Panel
     January 01, 2012 - She has worked on interdisciplinary teams across numerous practice settings and is currently leading … clinical leadership throughout his career, including developing new medical school courses and clerkships, leading … disparities, health equity, and patient safety to the initiative to uncover the contributing factors leading … Watson has been recognized as one of the 50 Experts Leading the Field of Patient Safety by Becker’s Hospital … Review, a leading healthcare publication.