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  1. 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
  2. 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
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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.
  8. 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
  9. 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.
  10. psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
    February 15, 2023 - Citation Related Resources From the Same Author(s) Mental health conditions leading
  11. 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
  12. psnet.ahrq.gov/issue/preventing-maternal-death
    April 26, 2023 - February 15, 2011 Epidural pump programming error leading to inadvertent 10-fold dosing
  13. 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.
  14. 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
  15. 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
  16. 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.
  17. 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
  18. 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
  19. 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
  20. 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 July 31, 2023 WebM&M Cases Misconnection Leading

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