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241. 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

242. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864858/psn-pdf
     March 20, 2024 - first-year-analysis-operating-room-black-box-study https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia

243. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864850/psn-pdf
     March 20, 2024 - adverse-events-near-misses-and-errors#:~:text=something%20wrong)%20or-,omission%20(failing%20to%20do%20the%20right%20thing),-leading

244. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38785/psn-pdf
     September 02, 2009 - ethnographic-study-classifying-and-accounting-risk-sharp-end-medical-wards https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

245. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43657/psn-pdf
     November 26, 2014 - ismps-list-high-alert-medications-acute-care-settings https://psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46026/psn-pdf
     May 03, 2017 - systematic-review-application-plan-do-study-act-method-improve-quality-healthcare https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

247. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41554/psn-pdf
     January 03, 2017 - using-root-cause-analysis-reduce-falls-injury-community-settings This study used root cause analysis (RCA) to identify hazards leading

248. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41273/psn-pdf
     June 01, 2012 - inappropriate-medication-use-elderly-results-quality-improvement-project-99-primary-care https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

249. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43118/psn-pdf
     April 16, 2014 - liquid medication administration, including assigning a standard unit of measure (milliliters), using leading

250. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47112/psn-pdf
     May 09, 2018 - This magazine article provides 34 tips from leading patient safety experts to assist patients in this

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42212/psn-pdf
     April 17, 2013 - incidence-and-preventability-adverse-drug-events-among-older-persons-ambulatory-setting https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38551/psn-pdf
     April 15, 2009 - adverseevent https://psnet.ahrq.gov/issue/ambulatory-care-adverse-events-and-preventable-adverse-events-leading-hospital-admission

253. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/867511
     January 01, 2025 - May 16, 2022 Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading … May 16, 2022 Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading

254. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41928/psn-pdf
     January 30, 2013 - perceived-causes-prescribing-errors-junior-doctors-hospital-inpatients-study- protect The causative factors leading

255. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45454/psn-pdf
     September 04, 2016 - psnet.ahrq.gov/issue/err-human-building-safer-health-system https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43366/psn-pdf
     March 04, 2015 - 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

257. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40011/psn-pdf
     November 17, 2010 - of central line–associated bloodstream infections represents one of the patient safety movement's leading

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45750/psn-pdf
     February 01, 2017 - cognitive-biases-associated-medical-decisions-systematic-review Cognitive bias can contribute to diagnostic error, leading

259. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35101/psn-pdf
     November 04, 2015 - authors suggest that growing financial constraints may limit a hospital’s investment in patient safety, leading

260. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38840/psn-pdf
     August 12, 2009 - but the requisitions themselves did not prompt clinicians to enter all the pertinent clinical data, leading