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461. Which Line: Ordering Provider or Proceduralist? | PSNet
     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

462. 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

463. New system for patients to report medical mistakes. | PSNet
     psnet.ahrq.gov/issue/new-system-patients-report-medical-mistakes
     May 16, 2008 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.

464. Identifying and Preventing Medication Errors. | PSNet
     psnet.ahrq.gov/issue/identifying-and-preventing-medication-errors
     September 29, 2017 - January 30, 2003 The Future of Nursing: Leading Change, Advancing Health.

465. Lessons in Patient Safety. | PSNet
     psnet.ahrq.gov/issue/lessons-patient-safety
     August 01, 2017 - May 9, 2015 Leading a Culture of Safety: a Blueprint for Success.

466. Statement on the prevention of retained foreign bodies after surgery. | PSNet
     psnet.ahrq.gov/issue/statement-prevention-retained-foreign-bodies-after-surgery
     October 15, 2018 - August 24, 2005 Leading a Culture of Safety: a Blueprint for Success.

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

468. The robot will see you now. | PSNet
     psnet.ahrq.gov/issue/robot-will-see-you-now
     June 02, 2010 - April 2, 2014 Leading change: why transformation efforts fail.

469. 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

470. 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

471. 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

472. "Superficial" Report Leads to "Deep" Problem | PSNet
     psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
     July 01, 2012 - this case, the DVT label in the final report either triggered recognition or generated new knowledge leading

473. Early identification and evaluation of severe pressure injuries. | PSNet
     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.

474. Looking to the future of patient safety. | PSNet
     psnet.ahrq.gov/issue/looking-future-patient-safety
     February 13, 2018 - July 29, 2009 System issues leading to "found-on-floor" incidents: a multi-incident analysis

475. How has the current economy affected patient safety? | PSNet
     psnet.ahrq.gov/issue/how-has-current-economy-affected-patient-safety
     May 07, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading

476. Inattentional blindness: what captures your attention? | PSNet
     psnet.ahrq.gov/issue/inattentional-blindness-what-captures-your-attention
     May 07, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading

477. Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized. | PSNet
     psnet.ahrq.gov/issue/oral-syringes-crucial-and-economical-risk-reduction-strategy-has-not-been-fully-utilized
     June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading

478. How to master the new art of training: teamwork on the fly. | PSNet
     psnet.ahrq.gov/issue/how-master-new-art-training-teamwork-fly
     June 28, 2011 - May 29, 2019 Leading change: why transformation efforts fail.

479. On the Edge: Nursing in the Age of Complexity. | PSNet
     psnet.ahrq.gov/issue/edge-nursing-age-complexity
     August 20, 2012 - February 17, 2010 Cascade iatrogenesis: factors leading to the development of adverse

480. JCAHO to launch global patient safety center: the initial focus will be on reviewing and publicizing research findings. | PSNet
     psnet.ahrq.gov/issue/jcaho-launch-global-patient-safety-center-initial-focus-will-be-reviewing-and-publicizing
     December 22, 2010 - 14, 2011 View More Related Resources Mental health conditions leading