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psnet.ahrq.gov/node/43629/psn-pdf
May 01, 2015 - A potential unintended consequence of decreased duty-hours is
decline in educational quality leading
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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
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psnet.ahrq.gov/issue/how-cisgender-clinicians-can-help-prevent-harm-during-encounters-transgender-patients
August 31, 2022 - May 17, 2023
Mental health conditions leading cause of pregnancy-related deaths.
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psnet.ahrq.gov/issue/how-health-care-changes-when-algorithms-start-making-diagnoses
May 29, 2019 - October 20, 2015
Leading change: why transformation efforts fail.
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psnet.ahrq.gov/issue/shared-mdis-can-cross-contamination-be-avoided
May 03, 2023 - Order scanning systems may pull multiple pages through the scanner at the same time, leading
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psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
November 13, 2019 - June 17, 2020
Mental health conditions leading cause of pregnancy-related deaths.
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psnet.ahrq.gov/issue/enhancing-patient-safety-and-reducing-errors-health-care
July 10, 2019 - May 9, 2015
Leading a Culture of Safety: a Blueprint for Success.
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psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
December 04, 2019 - March 30, 2022
Leading causes of anesthesia-related liability claims in ambulatory surgery
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psnet.ahrq.gov/issue/after-harm-medical-error-and-ethics-forgiveness
July 24, 2019 - July 5, 2008
Leading Health Care Transformation: A Primer for Clinical Leaders.
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psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
February 15, 2023 - Citation
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psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading
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psnet.ahrq.gov/issue/preventing-maternal-death
April 26, 2023 - February 15, 2011
Epidural pump programming error leading to inadvertent 10-fold dosing
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psnet.ahrq.gov/issue/safety-and-ethics-healthcare-guide-getting-it-right
May 21, 2019 - March 9, 2018
Leading Health Care Transformation: A Primer for Clinical Leaders.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
March 01, 2005 - http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm
Leading … Alcohol 85
Motor Vehicle Collision 43
Obesity and Mortality
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Leading … Alcohol 85
Motor Vehicle Collision 43
Obesity and Mortality
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Cause of Death
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Leading
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
March 01, 2005 - http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm
Leading … Alcohol 85
Motor Vehicle Collision 43
Obesity and Mortality
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0
0
0
Cause of Death
# (thousands)
Leading … Alcohol 85
Motor Vehicle Collision 43
Obesity and Mortality
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Cause of Death
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Leading
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Understand the key elements of a safe and effective written and verbal signout
List Kotter’s 8 steps to leading … X-ray of Pneumothorax
Kotter's 8-Step Approach to Leading Change
Establish urgency
Form a powerful … Leading change: why transformation efforts fail. Harv Bus Rev. March 1995.
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psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - pathophysiology is related to the effect of local anesthetics on blocking fast sodium (Na) channels, leading … communication between the operating room (OR) team members concerning the safe dosing of local anesthetics, leading … WebM&M Cases
Inadequate Anesthesia Preparation Leading
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psnet.ahrq.gov/web-mm/too-much-too-fast
June 14, 2019 - Acidosis, by contrast, leads to an increase in intracellular hydrogen ions, thereby leading to potassium … secondary to acute kidney injury or chronic kidney disease can decrease renal excretion of potassium, leading … Related Resources
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psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Risk arising from these incidents
Gentamicin is an aminoglycoside type antibiotic that is one of the leading … WebM&M Cases
Inadequate Anesthesia Preparation Leading … December 14, 2022
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse events … 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 … Cancer
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