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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.
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psnet.ahrq.gov/issue/robot-will-see-you-now
June 02, 2010 - April 2, 2014
Leading change: why transformation efforts fail.
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psnet.ahrq.gov/issue/identifying-and-preventing-medication-errors
September 29, 2017 - January 30, 2003
The Future of Nursing: Leading Change, Advancing Health.
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psnet.ahrq.gov/issue/new-system-patients-report-medical-mistakes
May 16, 2008 - March 15, 2017
Leading High-Reliability Organizations in Healthcare.
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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
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psnet.ahrq.gov/issue/va-takes-lead-paperless-care
March 27, 2013 - Newspaper/Magazine Article
VA takes the lead in paperless care.
Citation Text:
VA takes the lead in paperless care. Brown D.
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psnet.ahrq.gov/issue/tenfold-errors-can-lead-tragedy
February 21, 2007 - Newspaper/Magazine Article
Tenfold errors can lead to tragedy.
Citation Text:
Tenfold errors can lead to tragedy. Sipkoff M. Drug Topics. August 21, 2006.
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis
Citation Text:
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/after-error-speaking-out-about-patient-safety-save-lives
February 04, 2009 - March 15, 2017
Leading High-Reliability Organizations in Healthcare.
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psnet.ahrq.gov/issue/edge-nursing-age-complexity
August 20, 2012 - February 17, 2010
Cascade iatrogenesis: factors leading to the development of adverse
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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
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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
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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
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psnet.ahrq.gov/issue/how-master-new-art-training-teamwork-fly
June 28, 2011 - May 29, 2019
Leading change: why transformation efforts fail.
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psnet.ahrq.gov/issue/quality-improvement-series
July 05, 2013 - November 15, 2017
Effectively leading for quality.
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psnet.ahrq.gov/issue/jcaho-launch-global-patient-safety-center-initial-focus-will-be-reviewing-and-publicizing
December 22, 2010 - 14, 2011
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Leading High-Reliability Organizations in Healthcare.