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401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46504/psn-pdf
     February 22, 2018 - how-guiding-coalitions-promote-positive-culture-change-hospitals-longitudinal-mixed-methods https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44372/psn-pdf
     June 21, 2016 - These results add weight to concerns about unintended consequences of pay-for-performance programs leading

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46864/psn-pdf
     August 17, 2018 - However, alerts are pervasive and often irrelevant, leading patient safety experts to question whether

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39662/psn-pdf
     April 30, 2014 - autopsy studies indicates that thousands of patients die every year due to missed or delayed diagnoses, leading

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45681/psn-pdf
     January 25, 2017 - investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading

406. Medication Mix-Up Leads to Patient Death | PSNet
     psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
     July 08, 2022 - Cognitive Bias    Cognitive bias can contribute to errors in judgment or thinking leading to an incorrect … Medical error—the third leading cause of death in the US.

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851971/psn-pdf
     July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up July 31, 2023 … Failure to adhere to dietary restrictions leading to complications and poor follow-up. … https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow … passed distally and could not be https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow … However, the order was not known to all hospital staff, and it was not followed, leading to postponement

408. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
     January 01, 2024 - Spotlight Spotlight Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications … bodies associated with traumatic lacerations 3 3 Errors in Managing an Open Wound of the Elbow Leading … multiple operations and a prolonged hospital stay. 7 7 Errors in Managing an Open Wound of the Elbow Leading … would not have prevented the infection, it may have led to its earlier identification, potentially leading … was missed by the initial treating physician in 38%.8 Not surprisingly, missed foreign bodies are a leading

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38981/psn-pdf
     September 30, 2009 - computerized-decision-support-reduce-potentially-inappropriate-prescribing-older-emergency https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44305/psn-pdf
     January 22, 2016 - rates for teaching hospitals were higher than expected based on patient and hospital characteristics, leading

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45305/psn-pdf
     February 14, 2017 - improving-patient-safety-intensive-care-units-michigan https://psnet.ahrq.gov/primer/health-care-associated-infections https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45491/psn-pdf
     May 09, 2017 - design and underlying clinical decision support systems, as well as insufficient system flexibility leading

413. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43629/psn-pdf
     May 01, 2015 - A potential unintended consequence of decreased duty-hours is decline in educational quality leading

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38902/psn-pdf
     November 13, 2009 - parental-misinterpretations-over-counter-pediatric-cough-and-cold-medication-labels https://psnet.ahrq.gov/issue/medication-overdoses-leading-emergency-department-visits-among-children

415. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43553/psn-pdf
     August 28, 2017 - The most common harm was oversedation leading to apnea and requiring the use of reversal agents or prolonged

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41866/psn-pdf
     November 28, 2012 - events after hospital discharge and a growing policy focus on preventing readmissions, the factors leading

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41408/psn-pdf
     October 19, 2012 - review documents 35 cases of unsafe injection practices in the United States over the past decade, leading

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44004/psn-pdf
     September 01, 2016 - 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

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45097/psn-pdf
     May 09, 2017 - 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

420. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47228/psn-pdf
     August 09, 2018 - The group determined 25 strategies, including leading with an emphasis on respect and dignity, promoting