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  1. psnet.ahrq.gov/issue/preventing-maternal-death
    April 26, 2023 - February 15, 2011 Epidural pump programming error leading to inadvertent 10-fold dosing
  2. 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.
  3. 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.
  4. psnet.ahrq.gov/issue/early-identification-and-evaluation-severe-pressure-injuries
    October 10, 2018 - June 17, 2020 Mental health conditions leading cause of pregnancy-related deaths.
  5. psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
    June 03, 2020 - Audiovisual Presentation Unprofessional Behavior Leads to Complications. Citation Text: Unprofessional Behavior Leads to Complications. JN Learning. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download…
  6. 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
  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. 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
  10. 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
  11. psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - 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 … multicenter project in which a refined handoff bundle was implemented in nine pediatric residency programs in leading … Take-Home Points Communication and handoff failures are a leading root cause of sentinel events and
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading … 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
  13. 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.
  14. psnet.ahrq.gov/issue/promethazine-conundrum-iv-can-hurt-more-im-injection
    November 13, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading
  15. psnet.ahrq.gov/issue/building-culture-safety-health-care
    April 15, 2021 - January 9, 2024 WebM&M Cases Misconnection Leading to
  16. 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
  17. psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one
    December 09, 2020 - March 8, 2023 Mental health conditions leading cause of pregnancy-related deaths.
  18. 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.
  19. 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
  20. 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

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