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  1. Data docs. | PSNet

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

  2. 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.

  3. 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

  4. 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

  5. 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

  6. 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.

  7. 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.

  8. The Failure Issue. | PSNet

    psnet.ahrq.gov/issue/failure-issue
    October 20, 2015 - May 29, 2019 Leading change: why transformation efforts fail.

  9. 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.

  10. 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.

  11. 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

  12. 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

  13. 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

  14. 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

  15. "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

  16. When We Do Harm: A Doctor Confronts Medical Error. | PSNet

    psnet.ahrq.gov/issue/when-we-do-harm-doctor-confronts-medical-error
    July 24, 2018 - WebM&M Cases Failure to Adhere to Dietary Restrictions Leading

  17. Human factors in pediatric anesthesia incidents. | PSNet

    psnet.ahrq.gov/issue/human-factors-pediatric-anesthesia-incidents
    June 06, 2018 - March 15, 2017 Leading High-Reliability Organizations in Healthcare.

  18. Quality Improvement Series. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-series
    July 05, 2013 - November 15, 2017 Effectively leading for quality.

  19. 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

  20. Daily check-in for safety: from best practice to common practice. | PSNet

    psnet.ahrq.gov/issue/daily-check-safety-best-practice-common-practice
    February 13, 2018 - April 11, 2012 Leading clinical handover improvement: a change strategy to implement
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