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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. 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

64. Patient safety and telephone medicine: some lessons from closed claim case review. | PSNet
    psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review
    May 18, 2022 - accurately gauging illness severity and formulating an appropriate plan of action may be difficult , leading … Most cases alleged that clinicians failed to accurately diagnose the patient; types of errors leading … September 13, 2011 Ambulatory care adverse events and preventable adverse events leading

65. 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

66. Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic. | PSNet
    psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine
    September 29, 2021 - Commentary Organisational crisis resource management: leading an academic department … Organisational crisis resource management: leading an academic department of emergency medicine through … Organisational crisis resource management: leading an academic department of emergency medicine through

67. 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

68. 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/

69. 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

70. 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

71. Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events. | PSNet
    psnet.ahrq.gov/issue/occupational-therapy-utilization-veterans-dementia-retrospective-review-root-cause-analyses
    March 25, 2020 - therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading … therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading … therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading

72. 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

73. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
    psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. … would not have prevented the infection, it may have led to its earlier identification, potentially leading … Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations.

74. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet
    psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
    December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. … 4 weeks, prior history of DVT or PE, hemoptysis, malignancy within previous 6 months, and PE as the leading … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism.

75. 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

76. 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

77. 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

78. 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

79. New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. | PSNet
    psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved-care-and-savings
    October 31, 2014 - Book/Report New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved … Citation Text: New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and … Citation Citation Text: New HHS Data Shows Major Strides Made in Patient Safety, Leading

80. Leading article: how can I optimise my role as a leader within the surgical team? | PSNet
    psnet.ahrq.gov/issue/leading-article-how-can-i-optimise-my-role-leader-within-surgical-team
    October 29, 2017 - Review Leading article: how can I optimise my role as a leader within the surgical … 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?