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psnet.ahrq.gov/issue/assessing-impact-teaching-patient-safety-principles-medical-students-during-surgical
November 27, 2012 - found that teaching medical students practical applications of previously taught safety principles leads
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psnet.ahrq.gov/issue/effects-electrode-misplacement-clinicians-interpretation-standard-12-lead-electrocardiogram
February 10, 2016 - Misplacement of the electrical leads when performing a standard 12-lead electrocardiogram (ECG) significantly
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psnet.ahrq.gov/issue/safemedicationuseca
October 10, 2012 - September 9, 2015
Selection of incorrect medication pump leads to chemotherapy overdose
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psnet.ahrq.gov/issue/nutrition-support-safety
July 10, 2024 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - This state of low solute and high free water intake leads to hypotonic hyponatremia resulting in suppression … In patients in this state, administering solute via either isotonic or hypertonic saline leads to rapid … Related Resources
WebM&M Cases
Medication Mix-Up Leads
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psnet.ahrq.gov/issue/nurses-relate-contributing-factors-involved-medication-errors
February 18, 2009 - The investigators conducted a focus group to elicit nurses' perceptions of what leads to nursing medication
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psnet.ahrq.gov/issue/people-are-more-error-prone-after-committing-error
June 29, 2011 - post-error slowing is not simply due to increased caution, but due to impaired cognitive processing, and leads
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psnet.ahrq.gov/issue/pediatric-medication-errors-and-reduction-strategies-perioperative-period
October 19, 2022 - March 15, 2023
WebM&M Cases
Saline Flush Leads
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psnet.ahrq.gov/issue/apsf-stoelting-conference
September 19, 2024 - WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads
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psnet.ahrq.gov/issue/blaming-others-threatening-events
November 25, 2009 - personal characteristics, with interpersonal and intrapersonal mediators playing a role, which ultimately leads
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psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
November 16, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
September 15, 2021 - August 19, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
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psnet.ahrq.gov/issue/people-color-long-covid-face-uphill-battle-be-heard
August 24, 2022 - August 19, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
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psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings
January 26, 2023 - August 17, 2022
WebM&M Cases
Saline Flush Leads to Acute
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psnet.ahrq.gov/issue/how-pandemic-defeated-america
July 01, 2020 - June 17, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
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psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
April 22, 2020 - June 1, 2021
Electronic prescribing vulnerabilities: height and weight mix-up leads to
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psnet.ahrq.gov/issue/rfid-tags-reduce-restocking-errors-anesthesia-medications
August 07, 2019 - June 28, 2023
WebM&M Cases
Saline Flush Leads to Acute
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psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses
July 10, 2019 - August 5, 2020
When a vital sign leads a country astray—the opioid epidemic.
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psnet.ahrq.gov/issue/california-mans-painful-and-terrifying-road-monkeypox-diagnosis
August 17, 2022 - June 17, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
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psnet.ahrq.gov/issue/kaiser-permanentes-innovation-front-lines
January 20, 2021 - June 10, 2018
Misprogramming PCA concentration leads to dosing errors.