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81. 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

82. Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine. | PSNet
    psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural
    May 13, 2009 - Commentary Epidural pump programming error leading to inadvertent 10-fold dosing … Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural Labor Analgesia … Epidural Pump Programming Error Leading to Inadvertent 10-Fold Dosing Error During Epidural Labor Analgesia

83. Ambulatory care adverse events and preventable adverse events leading to a hospital admission. | PSNet
    psnet.ahrq.gov/issue/ambulatory-care-adverse-events-and-preventable-adverse-events-leading-hospital-admission
    April 11, 2011 - Study Ambulatory care adverse events and preventable adverse events leading to a … Ambulatory care adverse events and preventable adverse events leading to a hospital admission. … Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

84. PSNet Curated Library (pdf file)
    psnet.ahrq.gov/print/pdf/node/867659
    July 10, 2024 - Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism David Barnes, MD … hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism … Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism David Barnes, MD … surveillance-monitoring-improve-patient-safety-acute-hospital-care-units https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism

85. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72800/psn-pdf
    March 03, 2021 - deficits-communication-and-information-transfer-between-hospital-based-and-primary-care https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail … https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/853059/psn-pdf
    August 30, 2023 - issue/technology-education-and-safety-0 https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia … https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia

87. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. | PSNet
    psnet.ahrq.gov/issue/adverse-events-cough-and-cold-medications-after-market-withdrawal-products-labeled-infants
    August 02, 2015 - From the Same Author(s) National estimates of insulin-related hypoglycemia and errors leading … August 2, 2015 Medication use leading to emergency department visits for adverse drug … February 23, 2018 Medication overdoses leading to emergency department visits among children … November 25, 2009 Medication overdoses leading to emergency department visits among children

88. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
    psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - SPOTLIGHT CASE Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis … Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. … Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. … On inspection, the tracheal cuff had burst, leading to a severe leak in addition to a tracheal tear with … Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture..

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836865/psn-pdf
    April 06, 2022 - 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

90. Identifying factors leading to harm in English general practices: a mixed-methods study based on patient experiences integrating structural equation modeling and qualitative content analysis. | PSNet
    psnet.ahrq.gov/issue/identifying-factors-leading-harm-english-general-practices-mixed-methods-study-based-patient
    June 01, 2016 - Study Identifying factors leading to harm in English general practices: a mixed-methods … Identifying Factors Leading to Harm in English General Practices: A Mixed-Methods Study Based on Patient … Identifying Factors Leading to Harm in English General Practices: A Mixed-Methods Study Based on Patient

91. What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety. | PSNet
    psnet.ahrq.gov/issue/what-has-airbus-a380-captain-got-do-omfs-lessons-aviation-improve-patient-safety
    October 04, 2023 - Leading article: What has an Airbus A380 Captain got to do with OMFS? … Leading article: What has an Airbus A380 Captain got to do with OMFS? … February 18, 2011 Leading article: how can I optimise my role as a leader within the

92. CE/MOC Quizzes | PSNet
    psnet.ahrq.gov/cme
    February 26, 2025 - Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation … However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition … suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading … October 30, 2024 Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications … prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading

93. Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. | PSNet
    psnet.ahrq.gov/issue/medical-diagnoses-commonly-associated-pediatric-malpractice-lawsuits-united-states
    November 16, 2022 - Analysis of closed malpractice claims has been used to identify patterns of errors and system problems leading … of data from the Physicians Insurers Association of America focuses on specific pediatric diagnoses leading

94. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46787/psn-pdf
    October 15, 2018 - https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/issue/leading-strategic-planning-effort … https://psnet.ahrq.gov/issue/leading-strategic-planning-effort

95. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28 … Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. … https://psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis … this could happen, the patient developed increasing hypoxemia and respiratory distress, ultimately leading … On inspection, the tracheal cuff had burst, leading to a severe leak in addition to a tracheal tear with

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46156/psn-pdf
    July 11, 2017 - causes-death-residents-acgme-accredited-programs-2000-through-2014- implications-learning This retrospective cohort study found that the leading … cause of death among resident physicians is cancer, and the second leading cause of death is suicide

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43287/psn-pdf
    July 02, 2014 - in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading … in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/34690/psn-pdf
    February 10, 2011 - They found the leading cause of error was lack of drug knowledge on the part of the ordering physician … Overall, the authors describe 16 system failures leading to ADEs, with seven accounting for 78% of all

99. Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data. | PSNet
    psnet.ahrq.gov/issue/missed-diagnosis-cardiovascular-disease-outpatient-general-medicine-insights-malpractice
    December 22, 2018 - This analysis of closed malpractice claims sought to characterize the types of errors leading to malpractice … August 7, 2019 Leading causes of anesthesia-related liability claims in ambulatory surgery

100. Improving patient care. The cognitive psychology of missed diagnoses. | PSNet
     psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
     October 03, 2012 - While reviewing the details of the case, the author explores the pitfalls leading to missed diagnoses … March 20, 2013 Medication use leading to emergency department visits for adverse drug