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381. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43571/psn-pdf
     October 01, 2014 - evidence that walkrounds improved safety culture, this practice became widely endorsed by AHRQ and other leading

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40309/psn-pdf
     April 22, 2011 - Brent James—one of the nation's leading physician quality improvement experts—discussed his use of change

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45731/psn-pdf
     September 29, 2017 - example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading

384. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41795/psn-pdf
     September 07, 2016 - Although the details leading to the voluntary facility shutdown were not transparent, the authors suggest

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46197/psn-pdf
     September 24, 2017 - A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care

386. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41706/psn-pdf
     November 08, 2012 - An AHRQ WebM&M commentary discusses a case of medication error leading to a preventable readmission.

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40842/psn-pdf
     September 24, 2016 - A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44586/psn-pdf
     June 21, 2016 - important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49819/psn-pdf
     February 01, 2018 - Miscommunication has consistently been identified as one of the leading causes of serious adverse events … Commission, the Accreditation Council for Graduate Medical Education, and other regulatory agencies as a leading … project in which a refined handoff bundle was implemented in nine pediatric residency programs in leading … Take-Home Points https://psnet.ahrq.gov//#references Communication and handoff failures are a leading

390. Supporting second victims. | PSNet
     psnet.ahrq.gov/issue/supporting-second-victims
     February 15, 2023 - Citation Related Resources From the Same Author(s) Mental health conditions leading

391. Supporting safe, equitable care during the COVID-19 pandemic. | PSNet
     psnet.ahrq.gov/issue/supporting-safe-equitable-care-during-covid-19-pandemic
     March 02, 2022 - June 17, 2020 Mental health conditions leading cause of pregnancy-related deaths.

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49658/psn-pdf
     July 01, 2012 - The ED physician relied heavily on this documented triage complaint, leading to an overly focused history … This case exemplifies how multiple latent factors embedded in triage can initiate a cascade of events leading … Multiple latent factors embedded in triage can initiate a cascade of events leading to a diagnostic

393. Signout Fallout | PSNet
     psnet.ahrq.gov/web-mm/signout-fallout
     November 16, 2022 - Miscommunication has consistently been identified as one of the leading causes of serious adverse events … Commission, the Accreditation Council for Graduate Medical Education, and other regulatory agencies as a leading … multicenter project in which a refined handoff bundle was implemented in nine pediatric residency programs in leading … Take-Home Points Communication and handoff failures are a leading root cause of sentinel events and

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49855/psn-pdf
     March 01, 2019 - which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading … In medicine, the error is identified through inspection and corrected before leading to further harm … Successive check, with the interventional radiologist questioning the indication and leading to consultation … Take-Home Points Health care organizations must have systems in place to prevent inevitable errors from leading

395. HEAR Her Concerns. | PSNet
     psnet.ahrq.gov/issue/hear-her-concerns
     April 01, 2024 - February 22, 2023 Mental health conditions leading cause of pregnancy-related deaths.

396. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-470
     December 31, 2024 - 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

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43664/psn-pdf
     September 01, 2016 - Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable

398. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45714/psn-pdf
     December 20, 2017 - national-surveillance-emergency-department-visits-outpatient-adverse-drug-events https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

399. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39143/psn-pdf
     February 14, 2011 - impact-pharmacist-facilitated-hospital-discharge-program-quasi-experimental- study Medication errors are a leading

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44823/psn-pdf
     February 15, 2017 - Half were coded as "general unintentional," which includes exploratory exposures and other scenarios leading