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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45210/psn-pdf
     September 27, 2016 - Clinicians who are involved in an adverse event often experience significant emotional consequences, leading

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38645/psn-pdf
     February 15, 2011 - https://psnet.ahrq.gov/primer/medication-reconciliation https://psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults

423. "Superficial" Report Leads to "Deep" Problem | PSNet
     psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
     July 01, 2012 - this case, the DVT label in the final report either triggered recognition or generated new knowledge leading

424. Shared MDIs: can cross-contamination be avoided? | PSNet
     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

425. How health care changes when algorithms start making diagnoses. | PSNet
     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.

426. Enhancing Patient Safety and Reducing Errors in Health Care. | PSNet
     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.

427. Eliminating vincristine administration events. | PSNet
     psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
     February 15, 2023 - Citation Related Resources From the Same Author(s) Mental health conditions leading

428. Canadian Anesthesia Incident Reporting System. | PSNet
     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

429. After Harm: Medical Error and the Ethics of Forgiveness. | PSNet
     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.

430. Preventing maternal death. | PSNet
     psnet.ahrq.gov/issue/preventing-maternal-death
     April 26, 2023 - February 15, 2011 Epidural pump programming error leading to inadvertent 10-fold dosing

431. Safety and Ethics in Healthcare: A Guide to Getting it Right. | PSNet
     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.

432. Swiss Cheese Model | PSNet
     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

433. Advancing safety with closed-loop communication of test results. | PSNet
     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.

434. How cisgender clinicians can help prevent harm during encounters with transgender patients. | PSNet
     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.

435. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
     psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
     January 29, 2021 - WebM&M Cases Inadequate Anesthesia Preparation Leading … December 14, 2022 WebM&M Cases Misconnection Leading

436. Spotlight Case September 2006 (ppt file)
     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.

437. Spotlight Case [MONTH] 2003 (ppt file)
     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 0 0 0 0 Cause of Death # (thousands) Leading … Alcohol 85 Motor Vehicle Collision 43 Obesity and Mortality 0 0 0 0 Cause of Death # (thousands) Leading

438. Spotlight Case [MONTH] 2003 (ppt file)
     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 0 0 0 0 Cause of Death # (thousands) Leading … Alcohol 85 Motor Vehicle Collision 43 Obesity and Mortality 0 0 0 0 Cause of Death # (thousands) Leading

439. Too Much, Too Fast | PSNet
     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 WebM&M Cases Misconnection Leading

440. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. | PSNet
     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 WebM&M Cases Misconnection Leading