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61. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45357/psn-pdf
    October 09, 2016 - Leading article: how can I optimise my role as a leader within the surgical team? … Leading article: how can I optimise my role as a leader within the surgical team? … https://psnet.ahrq.gov/issue/leading-article-how-can-i-optimise-my-role-leader-within-surgical-team … https://psnet.ahrq.gov/issue/leading-article-how-can-i-optimise-my-role-leader-within-surgical-team https

62. Hindsight Bias | PSNet
    psnet.ahrq.gov/glossary/hindsight-bias
    September 13, 2021 - after learning the outcome of a series of events—whether the outcome of the World Series or the steps leading … In the context of safety analysis, hindsight bias refers to the tendency to judge the events leading … The more severe the outcome, the more likely that decisions leading up to this outcome will be judged

63. Leading quality and safety on the frontline - a case study of department leaders in nursing homes. | PSNet
    psnet.ahrq.gov/issue/leading-quality-and-safety-frontline-case-study-department-leaders-nursing-homes
    February 28, 2024 - Study Leading quality and safety on the frontline - a case study of department leaders … Leading quality and safety on the frontline - a case study of department leaders in nursing homes. … Leading quality and safety on the frontline - a case study of department leaders in nursing homes.

64. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. | PSNet
    psnet.ahrq.gov/issue/cascade-iatrogenesis-factors-leading-development-adverse-events-hospitalized-older-adults
    June 27, 2012 - Commentary Cascade iatrogenesis: factors leading to the development of adverse events … Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults … Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45005/psn-pdf
    May 04, 2016 - Leading High-Reliability Organizations in Healthcare. May 4, 2016 Morrow R. … https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare High reliability has … https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare https://psnet.ahrq.gov

66. Making hospital care safer and better: the structure-process connection leading to adverse events. | PSNet
    psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading-adverse-events
    November 04, 2020 - Study Making hospital care safer and better: the structure-process connection leading … Making hospital care safer and better: the structure-process connection leading to adverse events. … Making hospital care safer and better: the structure-process connection leading to adverse events.

67. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73097/psn-pdf
    March 31, 2011 - The Future of Nursing: Leading Change, Advancing Health. March 31, 2011 Institute of Medicine. … https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health The effective engagement … https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health https://psnet.ahrq.gov/primer

68. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. | PSNet
    psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care
    May 18, 2022 - Commentary Leading clinical handover improvement: a change strategy to implement … Leading Clinical Handover Improvement. … Leading Clinical Handover Improvement.

69. The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. | PSNet
    psnet.ahrq.gov/issue/nature-causes-and-clinical-impact-errors-clinical-laboratory-testing-process-leading
    May 18, 2022 - The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading … The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading … The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading

70. Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. | PSNet
    psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical
    June 02, 2021 - Study Investigation of urology intraoperative events leading to root cause analysis … Citation Text: Investigation of urology intraoperative events leading to root cause analysis at national … Cite Citation Citation Text: Investigation of urology intraoperative events leading

71. The evolving role of health educators in advancing patient safety: forging partnerships and leading change. | PSNet
    psnet.ahrq.gov/issue/evolving-role-health-educators-advancing-patient-safety-forging-partnerships-and-leading
    July 22, 2020 - The evolving role of health educators in advancing patient safety: forging partnerships and leading … The evolving role of health educators in advancing patient safety: forging partnerships and leading change … The evolving role of health educators in advancing patient safety: forging partnerships and leading change

72. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. | PSNet
    psnet.ahrq.gov/issue/mistaken-identity-skin-cleansing-solution-leading-extensive-chemical-burns-extremely-preterm
    October 19, 2022 - Commentary Mistaken identity of skin cleansing solution leading to extensive chemical … Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm … Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45113/psn-pdf
    May 11, 2016 - Medical error—the third leading cause of death in the US. May 11, 2016 Makary MA, Daniel M. … Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. … https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us How many patients die each year … https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us https://psnet.ahrq.gov/issue/

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45565/psn-pdf
    May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success. … https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success Health care leadership plays an … https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success https://psnet.ahrq.gov/primer/leadership-role-improving-safety

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34659/psn-pdf
    April 07, 2010 - Leading change: why transformation efforts fail. April 7, 2010 Kotter JP. … https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail Kotter, a professor at Harvard … https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44303/psn-pdf
    January 10, 2018 - Leading Health Care Transformation: A Primer for Clinical Leaders. … https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders Leadership can … https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders https://psnet.ahrq.gov

77. Medication use leading to emergency department visits for adverse drug events in older adults. | PSNet
    psnet.ahrq.gov/issue/medication-use-leading-emergency-department-visits-adverse-drug-events-older-adults
    March 05, 2008 - Study Classic Medication use leading to emergency department … Medication use leading to emergency department visits for adverse drug events in older adults. … Medication use leading to emergency department visits for adverse drug events in older adults. … January 18, 2011 Medication overdoses leading to emergency department visits among children

78. Emergency hospitalizations for adverse drug events in older Americans. | PSNet
    psnet.ahrq.gov/issue/emergency-hospitalizations-adverse-drug-events-older-americans
    October 20, 2021 - February 23, 2018 National estimates of insulin-related hypoglycemia and errors leading … August 2, 2015 Medication use leading to emergency department visits for adverse drug … June 16, 2019 National estimates of insulin-related hypoglycemia and errors leading to … August 2, 2015 Medication use leading to emergency department visits for adverse drug

79. Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet
    psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident
    March 11, 2020 - lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading … lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading … lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading

80. Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. | PSNet
    psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-leading-drug
    June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading … Citation Text: Order scanning systems may pull multiple pages through the scanner at the same time, leading … Citation Text: Order scanning systems may pull multiple pages through the scanner at the same time, leading