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21. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73922/psn-pdf
    October 06, 2021 - Leading causes of anesthesia-related liability claims in ambulatory surgery centers. … Leading causes of anesthesia-related liability claims in ambulatory surgery centers. … https://psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers … This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims … https://psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers

22. High reliability in a safety net hospital leading to operational excellence. | PSNet
    psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence
    March 01, 2011 - Study High reliability in a safety net hospital leading to operational excellence … High reliability in a safety net hospital leading to operational excellence. … High reliability in a safety net hospital leading to operational excellence.

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60986/psn-pdf
    January 01, 2021 - Organisational crisis resource management: leading an academic department of emergency medicine through … Organisational crisis resource management: leading an academic department of emergency medicine through … https://psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department- … https://psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine … https://psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine

24. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854818/psn-pdf
    October 25, 2023 - The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading … The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading … psnet.ahrq.gov/issue/nature-causes-and-clinical-impact-errors-clinical-laboratory-testing-process- leading … //psnet.ahrq.gov/issue/nature-causes-and-clinical-impact-errors-clinical-laboratory-testing-process-leading … //psnet.ahrq.gov/issue/nature-causes-and-clinical-impact-errors-clinical-laboratory-testing-process-leading

25. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72637/psn-pdf
    January 13, 2021 - Identifying factors leading to harm in English general practices: a mixed-methods study based on patient … Identifying Factors Leading to Harm in English General Practices: A Mixed-Methods Study Based on Patient … https://psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods … https://psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods-study-based-patient … https://psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods-study-based-patient

26. Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic. | PSNet
    psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine
    September 29, 2021 - Commentary Organisational crisis resource management: leading an academic department … Organisational crisis resource management: leading an academic department of emergency medicine through … Organisational crisis resource management: leading an academic department of emergency medicine through

27. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
    psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - SPOTLIGHT CASE CME/MOC Errors in Managing an Open Wound of the Elbow Leading … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. … would not have prevented the infection, it may have led to its earlier identification, potentially leading … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations.

28. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia | PSNet
    psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation … Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. … Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. … Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. … December 14, 2022 WebM&M Cases Misconnection Leading

29. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866521/psn-pdf
    August 14, 2024 - High reliability in a safety net hospital leading to operational excellence. … High reliability in a safety net hospital leading to operational excellence. … https://psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence Health … https://psnet.ahrq.gov/issue/high-reliability-safety-net-hospital-leading-operational-excellence https

30. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/851656/psn-pdf
    July 26, 2023 - Investigation of urology intraoperative events leading to root cause analysis at national VA medical … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis- … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical

31. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/852284/psn-pdf
    August 09, 2023 - ‘Medical errors are the third leading cause of death’ and other statistics you should question. … https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should … https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should-question … https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should-question

32. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet
    psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
    December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. … 4 weeks, prior history of DVT or PE, hemoptysis, malignancy within previous 6 months, and PE as the leading … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism.

33. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40262/psn-pdf
    March 02, 2011 - Leading clinical handover improvement: a change strategy to implement best practices in the acute care … Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. … https://psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best- practices-acute-care … https://psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care … https://psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38937/psn-pdf
    September 23, 2009 - Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults … Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults … https://psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events- hospitalized-older-adults … https://psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults … https://psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults

35. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36799/psn-pdf
    November 28, 2016 - The evolving role of health educators in advancing patient safety: forging partnerships and leading … The evolving role of health educators in advancing patient safety: forging partnerships and leading … psnet.ahrq.gov/issue/evolving-role-health-educators-advancing-patient-safety-forging-partnerships- and-leading … psnet.ahrq.gov/issue/evolving-role-health-educators-advancing-patient-safety-forging-partnerships-and-leading … psnet.ahrq.gov/issue/evolving-role-health-educators-advancing-patient-safety-forging-partnerships-and-leading

36. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37201/psn-pdf
    October 06, 2011 - Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm … Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm … https://psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns … https://psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm … https://psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm

37. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40070/psn-pdf
    December 08, 2010 - Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia … Epidural Pump Programming Error Leading to Inadvertent 10- Fold Dosing Error During Epidural Labor Analgesia … https://psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error … https://psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural … https://psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural

38. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34960/psn-pdf
    June 22, 2009 - Making hospital care safer and better: the structure- process connection leading to adverse events. … Making hospital care safer and better: the structure-process connection leading to adverse events. … https://psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading … https://psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading-adverse-events … https://psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading-adverse-events

39. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72670/psn-pdf
    January 27, 2021 - System issues leading to "found-on-floor" incidents: a multi-incident analysis. … System Issues Leading to “Found-on-Floor” Incidents: A Multi- Incident Analysis. … https://psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis Patients … https://psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis https

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43075/psn-pdf
    August 02, 2015 - National estimates of insulin-related hypoglycemia and errors leading to emergency department visits … National estimates of insulin-related hypoglycemia and errors leading to emergency department visits … https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading- emergency-department … https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department … https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department