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181. 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

182. 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

183. 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

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855106/psn-pdf
     November 08, 2023 - home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among https://psnet.ahrq.gov/primer/falls https://psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis

185. 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

186. 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

187. 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

188. 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

189. 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

190. 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

191. 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

192. 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

193. 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

194. 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

195. 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

196. 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

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38978/psn-pdf
     January 04, 2010 - unintended-exposure-radiotherapy-identification-prominent-causes This study used root cause analysis methodology to identify system factors leading

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39448/psn-pdf
     May 20, 2015 - patient-safety-handbook-ambulatory-care-providers https://psnet.ahrq.gov/issue/ambulatory-care-adverse-events-and-preventable-adverse-events-leading-hospital-admission

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43267/psn-pdf
     June 11, 2014 - protect-initiative-advancing-childrens-medication-safety https://psnet.ahrq.gov/issue/medication-overdoses-leading-emergency-department-visits-among-children

200. 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.