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181. When COVID-19 hit, many elderly were left to die. | PSNet
     psnet.ahrq.gov/issue/when-covid-19-hit-many-elderly-were-left-die
     June 24, 2020 - November 10, 2021 When medical care leads to harm—difficulty finding words: a teachable … February 10, 2015 Fear of Covid-19 leads other patients to decline critical treatment

182. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49752/psn-pdf
     January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn January 1, 2016 Maibach HI. … Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016. … https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn The Case A 31-year-old woman … https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn By the end of World War II

183. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4h_pdi10-sepsis-bestpractices.pdf
     May 17, 2016 - SurvivingSepsis/SSC-Pediatric- Guidelines.mp4 • AHRQ Innovations Exchange: Emergency Department Protocol Leads … Pediatric Patients With Sepsis https://innovations.ahrq.gov/profiles/emergency-department-protocol-leads-faster … SurvivingSepsis/SSC-Pediatric-Guidelines.mp4 https://innovations.ahrq.gov/profiles/emergency-department-protocol-leads-faster-identification-and-treatment-pediatric-patients … https://innovations.ahrq.gov/profiles/emergency-department-protocol-leads-faster-identification-and-treatment-pediatric-patients

184. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4v_combo_pdi10-sepsis-bestpractices.pdf
     May 17, 2016 - SurvivingSepsis/SSC-Pediatric- Guidelines.mp4 • AHRQ Innovations Exchange: Emergency Department Protocol Leads … Pediatric Patients With Sepsis https://innovations.ahrq.gov/profiles/emergency-department-protocol-leads-faster … SurvivingSepsis/SSC-Pediatric-Guidelines.mp4 https://innovations.ahrq.gov/profiles/emergency-department-protocol-leads-faster-identification-and-treatment-pediatric-patients … https://innovations.ahrq.gov/profiles/emergency-department-protocol-leads-faster-identification-and-treatment-pediatric-patients

185. Progress with preventing name confusion errors. | PSNet
     psnet.ahrq.gov/issue/progress-preventing-name-confusion-errors
     May 07, 2018 - September 14, 2016 Electronic prescribing vulnerabilities: height and weight mix-up leads … June 10, 2018 Misprogramming PCA concentration leads to dosing errors.

186. Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning. | PSNet
     psnet.ahrq.gov/issue/proper-positioning-pharmacy-label-hospira-pca-vials-will-avoid-interference-scanning
     May 05, 2018 - Related Resources From the Same Author(s) Misprogramming PCA concentration leads … June 16, 2019 Misprogramming PCA concentration leads to dosing errors.

187. Human costs of training doctors. | PSNet
     psnet.ahrq.gov/issue/human-costs-training-doctors
     December 17, 2014 - December 17, 2014 Parkland knee surgery done by doctor in training leads to amputation … January 14, 2011 Parkland knee surgery done by doctor in training leads to amputation

188. CDSiC Stakeholder Community and Outreach Center: Quarterly Report (pdf file)
     cdsic.ahrq.gov/sites/default/files/2024-02/CDSiC%20Stakeholder%20Center%20Quarterly%20Report%20Q4%202023_0.pdf
     January 01, 2024 - Priyanka Desai, PhD, MSPH, from NORC leads the Stakeholder Center. … Each Workgroup is led by two Co-Leads (see Exhibit 1). … Workgroup leads set the overall direction for the development of Workgroup products, facilitate meetings … Workgroup Leadership Workgroup Workgroup Co-Leads (Affiliation) Measurement and Outcomes ■ Polina … Additionally, the Planning Committee will meet as an opportunity for Workgroup Leads to share findings

189. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
     August 20, 2015 - The Implementation Team Lead and other Team Leads help build and promote a shared vision of organizational … The CANDOR Implementation Team Lead and Team Leads play an important role in ensuring that frontline … Coach team leads to motivate and inspire. Reinforce positive experiences. … Team leads should continue to be coached to motivate leaders and team members to support program interventions … Encourage your Team Leads to discuss actual CANDOR events to drive home important lessons.

190. Module 8: Organizational Learning and Sustainability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
     August 01, 2022 - The Implementation Team Lead and other Team Leads help build and promote a shared vision of organizational … The CANDOR Implementation Team Lead and Team Leads play an important role in ensuring that frontline … Team leads should continue to be coached to motivate leaders and team members to support program interventions … Encourage your Team Leads to discuss actual CANDOR events to drive home important lessons.

191. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Ginsberg (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-unc-webcast-ginsberg.pdf
     June 02, 2025 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture

192. Behavioral Counseling Interventions: An Evidence-based Approach - Figure 2 | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/behavioral-counseling-interventions-evidence-based-approach-figure-2
     November 01, 2013 - An arrow leads from this assessment arrow below to potential "Adverse Effects" (key question 4). … Staying on the same line, the "Intervention" arrow leads to the next box "Measures of Behavior Change … This arrow leads to a final box on the line "Ongoing or Sustained Behavior Change."

193. Misidentification of alphanumeric symbols in both handwritten and computer-generated information. | PSNet
     psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols-both-handwritten-and-computer-generated-information
     May 07, 2018 - Related Resources From the Same Author(s) Failed check system for chemotherapy leads … June 10, 2018 Failed check system for chemotherapy leads to pharmacist's "no contest"

194. ISMP updates its list of drug name pairs with Tall man letters. | PSNet
     psnet.ahrq.gov/issue/ismp-updates-its-list-drug-name-pairs-tall-man-letters
     June 10, 2018 - From the Same Author(s) Electronic prescribing vulnerabilities: height and weight mix-up leads … May 7, 2018 Misprogramming PCA concentration leads to dosing errors.

195. Misidentification of alphanumeric symbols. | PSNet
     psnet.ahrq.gov/issue/misidentification-alphanumeric-symbols
     March 26, 2014 - September 14, 2022 WebM&M Cases Saline Flush Leads to … August 5, 2020 Incorrect use of smart infusion pump in the operating room (OR) leads

196. Operations Center: Operational Framework – Option Year 2 (pdf file)
     cdsic.ahrq.gov/sites/default/files/2025-03/Operations%20Center%20OY2%20Operational%20Framework_508.pdf
     January 01, 2025 - Management Meeting To discuss project management for the overall project Project Management and Task Leads … Project Directorate CDSiC Operations Center Leadership Workgroup and Innovation Core Leads … They will receive interim update presentations by Workgroup Leads and Innovation Core Leads. … As such, Steering Committee members will: ■ Receive update presentations by Workgroup Leads and Innovation … Core Leads ■ Review and provide input on select products as requested by the Operations Center leadership

197. Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups? | PSNet
     psnet.ahrq.gov/issue/survey-lasa-drug-name-pairs-who-knows-whats-your-list-and-best-ways-prevent-mix-ups
     June 10, 2018 - November 3, 2021 The absence of a drug–disease interaction alert leads to a child's death … January 23, 2019 Misprogramming PCA concentration leads to dosing errors.

198. Error | PSNet
     psnet.ahrq.gov/taxonomy/term/3475
     June 09, 2025 - Error An act of commission (doing something wrong) or omission (failing to do the right thing) that leads

199. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
     psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
     March 09, 2022 - SPOTLIGHT CASE Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads … Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and … Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and … Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and

200. Siegel, Corey | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/siegel-corey
     January 01, 2023 - Siegel, Corey Crohn's disease shared decision making intervention leads … Crohn's disease shared decision making intervention leads to more patients choosing combination therapy