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421. 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

422. 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

423. 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

424. 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

425. 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

426. 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

427. 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

428. 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

429. 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

430. 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

431. 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

432. 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

433. Infused, Not Ingested | PSNet
     psnet.ahrq.gov/web-mm/infused-not-ingested
     February 01, 2017 - the nurse tried to conceal and not address the error, he moved beyond human error (lack of judgment leading … development.( 11,12 ) Although individual nurses are, and should be, held accountable for their actions leading … WebM&M Cases Refused Medication Error February 1, 2017 Leading … WebM&M Cases Errors in Managing an Open Wound of the Elbow Leading

434. Using preprinted medication order forms to improve the safety of investigational drug use. | PSNet
     psnet.ahrq.gov/issue/using-preprinted-medication-order-forms-improve-safety-investigational-drug-use
     April 24, 2024 - October 20, 2021 National estimates of insulin-related hypoglycemia and errors leading

435. 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

436. 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

437. Surgical Patient Safety Essential Information for Surgeons in Today's Environment. | PSNet
     psnet.ahrq.gov/issue/surgical-patient-safety-essential-information-surgeons-todays-environment
     October 15, 2018 - January 13, 2016 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. 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.

440. 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