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441. Strategies for optimizing OR drug safety. | PSNet
     psnet.ahrq.gov/issue/strategies-optimizing-or-drug-safety
     November 30, 2022 - Order scanning systems may pull multiple pages through the scanner at the same time, leading

442. Patient safety in cataract surgery. | PSNet
     psnet.ahrq.gov/issue/patient-safety-cataract-surgery
     September 23, 2020 - July 13, 2010 National estimates of insulin-related hypoglycemia and errors leading to

443. Why accountability sharing in health care organizational cultures means patients are probably safer. | PSNet
     psnet.ahrq.gov/issue/why-accountability-sharing-health-care-organizational-cultures-means-patients-are-probably
     May 27, 2020 - September 30, 2020 Leading a highly visible hospital through a serious reportable event

444. Ensuring critical instruments and devices are appropriate for reuse. | PSNet
     psnet.ahrq.gov/issue/ensuring-critical-instruments-and-devices-are-appropriate-reuse
     February 17, 2021 - June 17, 2020 Mental health conditions leading cause of pregnancy-related deaths.

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42968/psn-pdf
     February 26, 2014 - However, as with CPOE in general, increasing use of e-prescribing is leading to greater recognition of

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47267/psn-pdf
     September 05, 2018 - adult inpatient discharges generating anywhere from 1.02 billion to 1.07 billion medication orders and leading

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44026/psn-pdf
     November 03, 2015 - effect-postdischarge-virtual-ward-readmission-or-death-high-risk-patients-randomized-clinical https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved-care-and-savings

448. U.S. inaction lets look-alike tubes kill patients. | PSNet
     psnet.ahrq.gov/issue/us-inaction-lets-look-alike-tubes-kill-patients
     September 01, 2008 - Medication Safety March 31, 2022 Investigation of urology intraoperative events leading

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45036/psn-pdf
     February 15, 2017 - who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading

450. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
     November 01, 2003 - clinical consequences to the patient Poor communication among team members Possible Factors Leading … System Failures Leading to Communication Breakdown Differences between team members’ goals Differences

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33689/psn-pdf
     October 01, 2009 - Perhaps the two biggest were those leading to the deaths of Libby Zion in New York Hospital in 1984 … amputated University Community Hospital, Tampa, FL 1995 New focus on wrong-site surgery, ultimately leading … dehydration Johns Hopkins Hospital 2001 Josie's parents form an alliance with Johns Hopkins' leadership (leading

452. Misleading Complaint | PSNet
     psnet.ahrq.gov/web-mm/misleading-complaint
     December 01, 2009 - 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 error

453. Hazards of Loading Doses | PSNet
     psnet.ahrq.gov/web-mm/hazards-loading-doses
     December 01, 2003 - Phenytoin was listed as the fourth leading drug associated with loading dose incidents, behind only warfarin … WebM&M Cases Failure to Adhere to Dietary Restrictions Leading … July 31, 2023 WebM&M Cases Misconnection Leading

454. Data docs. | PSNet
     psnet.ahrq.gov/issue/data-docs
     March 02, 2016 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.

455. How business intelligence can improve patient safety. | PSNet
     psnet.ahrq.gov/issue/how-business-intelligence-can-improve-patient-safety
     June 27, 2018 - June 15, 2011 System issues leading to "found-on-floor" incidents: a multi-incident analysis

456. The best medicine for fixing the modern hospital. | PSNet
     psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
     February 06, 2008 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.

457. The Failure Issue. | PSNet
     psnet.ahrq.gov/issue/failure-issue
     October 20, 2015 - May 29, 2019 Leading change: why transformation efforts fail.

458. Enhancing Surgical Performance: A Primer in Non-technical Skills. | PSNet
     psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills
     January 10, 2018 - Copy Citation Related Resources From the Same Author(s) Leading Health Care

459. Patient Safety: A Human Factors Approach. | PSNet
     psnet.ahrq.gov/issue/patient-safety-human-factors-approach
     January 01, 2019 - August 24, 2017 Leading Health Care Transformation: A Primer for Clinical Leaders.

460. Patient Safety: Exploring Quality of Care in the US. | PSNet
     psnet.ahrq.gov/issue/patient-safety-exploring-quality-care-us
     December 03, 2018 - February 24, 2025 ‘Medical errors are the third leading cause of death’ and other statistics