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psnet.ahrq.gov/issue/path-safe-and-reliable-healthcare
August 20, 2018 - August 26, 2011
An anesthesiology department leads culture change at a hospital system
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psnet.ahrq.gov/issue/ongoing-quality-improvement-journey-next-stop-high-reliability
January 23, 2012 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - November 4, 2015
When diagnostic testing leads to harm: a new outcomes-based approach
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psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
March 09, 2016 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared
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psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
February 24, 2016 - December 2, 2015
The absence of a drug–disease interaction alert leads to a child's death
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psnet.ahrq.gov/issue/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
September 18, 2013 - March 2, 2022
WebM&M Cases
"Superficial" Report Leads
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - However, controlled clinical studies have shown that spironolactone is far superior—its use leads to … Many of these patients have elevated circulating aldosterone concentrations, which leads to avid salt … The vasodilatation that occurs in the splanchnic bed leads to a lowering of mean arterial pressure and
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Anything that leads to decreased stooling will tend to increase this enterohepatic circulation; most … This leads to unnecessary separation of mother and infant and extra costs. … This typically leads to a gradually worsening anemia, rather than a stable hemoglobin for 10 days followed
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Inflammation
of the respiratory epithelium lining the paranasal sinuses (most commonly the maxillary sinuses) leads … This process leads to the typical sinus symptoms of headache, nasal
congestion and discharge, and facial … Antibiotic use leads to AMR by two mechanisms: creation of a susceptible host by eliminating an
individual's
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psnet.ahrq.gov/issue/effect-organizational-network-patient-safety-safety-event-reporting
October 16, 2013 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads
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psnet.ahrq.gov/issue/using-multi-method-user-centred-prospective-hazard-analysis-assess-care-quality-and-patient
May 27, 2011 - Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads
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psnet.ahrq.gov/issue/crises-clinical-care-approach-management
March 23, 2011 - WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads
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psnet.ahrq.gov/issue/results-survey-pediatric-medication-safety-part-1-and-part-2
November 16, 2015 - June 15, 2022
The absence of a drug–disease interaction alert leads to a child's death
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psnet.ahrq.gov/issue/using-enhanced-oral-chemotherapy-computerized-provider-order-entry-system-reduce-prescribing
October 20, 2014 - May 11, 2019
Electronic prescribing vulnerabilities: height and weight mix-up leads to
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psnet.ahrq.gov/issue/need-risk-profiling-patient-safety
August 08, 2010 - August 20, 2014
When diagnostic testing leads to harm: a new outcomes-based approach
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psnet.ahrq.gov/issue/hospital-credentialing-and-privileging-surgeons-potential-safety-blind-spot
September 24, 2017 - Summary
July 23, 2024
WebM&M Cases
Saline Flush Leads
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psnet.ahrq.gov/issue/ball-leadership-patient-safety-and-learning-critical-care
October 16, 2013 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads
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psnet.ahrq.gov/issue/oxytocin-high-alert-medication-implications-perinatal-patient-safety
September 29, 2010 - Related Resources
WebM&M Cases
Sleep Deprivation Leads
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psnet.ahrq.gov/issue/when-systems-fail
February 10, 2011 - April 14, 2021
Error in body weight estimation leads to inadequate parenteral anticoagulation
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psnet.ahrq.gov/issue/identifying-organizational-cultures-promote-patient-safety
June 16, 2011 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads