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441. 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

442. 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

443. 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

444. 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

445. 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

446. 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

447. 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

448. Building a Culture of Safety in Health Care. | PSNet
     psnet.ahrq.gov/issue/building-culture-safety-health-care
     April 15, 2021 - January 9, 2024 WebM&M Cases Misconnection Leading to

449. To combat physician burnout and improve care, fix the electronic health record. | PSNet
     psnet.ahrq.gov/issue/combat-physician-burnout-and-improve-care-fix-electronic-health-record
     November 14, 2018 - October 20, 2015 Leading change: why transformation efforts fail.

450. Administrative issues to ensure safe anesthesia care in the office-based setting. | PSNet
     psnet.ahrq.gov/issue/administrative-issues-ensure-safe-anesthesia-care-office-based-setting
     March 27, 2019 - March 27, 2019 Leading causes of anesthesia-related liability claims in ambulatory surgery

451. 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

452. Relationships among teams, culture, safety, and cost outcomes. | PSNet
     psnet.ahrq.gov/issue/relationships-among-teams-culture-safety-and-cost-outcomes
     January 30, 2019 - June 9, 2009 Leading your organization to high reliability.

453. How to Stay Safe When Entering the Healthcare System: A Physician Walks across the Country to Raise Awareness of the Need to Improve Healthcare Safety. | PSNet
     psnet.ahrq.gov/issue/how-stay-safe-when-entering-healthcare-system-physician-walks-across-country-raise-awareness
     January 01, 2019 - April 17, 2018 Leading High-Reliability Organizations in Healthcare.

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

455. 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.

456. 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

457. 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

458. 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

459. 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.

460. 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