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  1. 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
  2. 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
  3. psnet.ahrq.gov/issue/patient-safety-cataract-surgery
    September 23, 2020 - July 13, 2010 National estimates of insulin-related hypoglycemia and errors leading to
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. psnet.ahrq.gov/issue/data-docs
    March 02, 2016 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.
  15. psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
    February 06, 2008 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.
  16. 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
  17. psnet.ahrq.gov/issue/failure-issue
    October 20, 2015 - May 29, 2019 Leading change: why transformation efforts fail.
  18. psnet.ahrq.gov/issue/robot-will-see-you-now
    June 02, 2010 - April 2, 2014 Leading change: why transformation efforts fail.
  19. 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
  20. psnet.ahrq.gov/issue/patient-safety-human-factors-approach
    January 01, 2019 - August 24, 2017 Leading Health Care Transformation: A Primer for Clinical Leaders.

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