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421. 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

422. 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

423. 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

424. 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

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851158/psn-pdf
     June 28, 2023 - there is little published information on these rare events, the risk of all bleeding complications leading … wire was used to cross the valve in this case, but contrast was injected through the MPA catheter leading … Contrast injection was performed, which resulted in ventricular perforation, leading to rapid accumulation

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/863649/psn-pdf
     February 28, 2024 - Editor’s note: Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading … My professional focus has been on leading quality improvement projects. … I was also involved with leading the AHRQ-funded National Training program and leading national conferences … Monika has been leading AHRQ’s efforts in the diagnostic error realm, so I know that that’s a topic

427. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/866782
     August 28, 2024 - , 2024 Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading … managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33578/psn-pdf
     September 15, 2024 - Newborns in a neonatal intensive care unit are given full-dose heparin instead of low-dose flushes, leading … workarounds-barcode-medication-administration-systems-their-occurrences-causes-and-threats https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis

429. Unprofessional Behavior Leads to Complications. | PSNet
     psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
     June 03, 2020 - Audiovisual Presentation Unprofessional Behavior Leads to Complications. Citation Text: Unprofessional Behavior Leads to Complications. JN Learning. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download…

430. Looking Collectively at Risk. | PSNet
     psnet.ahrq.gov/issue/looking-collectively-risk
     December 19, 2018 - Practices Copy Citation Related Resources From the Same Author(s) Leading

431. 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

432. 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

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. 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.

435. 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.

436. 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

437. 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.

438. 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.

439. 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

440. 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