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341. Elizabeth Cope, PhD, MPH | CDSiC
     cdsic.ahrq.gov/cdsic/Elizabeth-Cope
     In addition to her work on CDSiC, she currently leads the coordinating center for the HRSA-funded Enhancing … She also leads the Learning Community for the AHRQ-funded EvidenceNOW: Managing Urinary Incontinence

342. 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.

343. 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.

344. 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

345. Horizon-Scan Research-Protocol (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/horizon-scan_research-protocol.pdf
     December 01, 2011 - Populating the “Initial Leads List” to develop topics After searchers have collected leads from broad … scanning using the above criteria, leads are uploaded to the Initial Leads List. … This is a document library containing all leads identified by searchers as well as leads generated … The analysts classify leads by topic class (see below). … The horizon scanning analysts then link related leads from the Initial Leads List to the appropriate

346. Horizon-Scan Research-Protocol (pdf file)
     effectivehealthcare-admin.ahrq.gov/sites/default/files/pdf/horizon-scan_research-protocol.pdf
     December 01, 2011 - Populating the “Initial Leads List” to develop topics After searchers have collected leads from broad … scanning using the above criteria, leads are uploaded to the Initial Leads List. … This is a document library containing all leads identified by searchers as well as leads generated … The analysts classify leads by topic class (see below). … The horizon scanning analysts then link related leads from the Initial Leads List to the appropriate

347. Falls Prevention Awareness Week 2024 | PSNet
     psnet.ahrq.gov/curated-library/falls-prevention-awareness-week-2024
     September 07, 2019 - WebM&Ms (1) Spotlight Case CME/MOC Failure to Ensure Patient Safety Leads … CME/MOC Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.

348. 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

349. TeamSTEPPS for Office-Based Care: Communication | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/officebasedcare/module3/office_comm.html
     September 01, 2015 - This leads to "Closed," which goes through "Receiver accepts message and provides feedback confirmation … This leads to "Loop," which goes through "Sender verifies message was received." … This leads back to "Communication," which continues the process.

350. 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

351. 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.

352. 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"

353. 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

354. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
     psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
     March 25, 2020 - VF) may be induced by attempted cardioversion. 8 It is therefore very important to connect the ECG leads … This may take place in the electrophysiology lab or in the operating room where pacing via epicardial leads … team forgetting to check that the cardioverter/defibrillator had been hooked up correctly to the ECG leads … With this set-up, a separate pair of chest leads directly connected to the defibrillator is no longer … May 16, 2022 WebM&M Cases Saline Flush Leads to

355. AHRQ Impact Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/index.html?page=11
     November 01, 2014 - 15 16 … next › ›› last » Last » AHRQ's RED Toolkit Leads … States of America Implementer: Mayo Clinic Date: October 2014 AHRQ’s Care Coordination Work Leads

356. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Slide 3 Say: Response and Disclosure is led by a team of trained Disclosure Leads. … The organization should identify a team of Disclosure Leads who can develop the knowledge, skills, and … Several tools in the toolkit can be used to identify Disclosure Leads and help them train and prepare … This tool can help assess readiness and attitudes of potential staff members to serve as Disclosure Leads … The Disclosure Checklist is a reference tool that provides Disclosure Leads and staff with the basic

357. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Slide 3 Say: Response and Disclosure is led by a team of trained Disclosure Leads. … The organization should identify a team of Disclosure Leads who can develop the knowledge, skills, and … Several tools in the toolkit can be used to identify Disclosure Leads and help them train and prepare … This tool can help assess readiness and attitudes of potential staff members to serve as Disclosure Leads … The Disclosure Checklist is a reference tool that provides Disclosure Leads and staff with the basic

358. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Slide 3 Say: Response and Disclosure is led by a team of trained Disclosure Leads. … The organization should identify a team of Disclosure Leads who can develop the knowledge, skills, and … Several tools in the toolkit can be used to identify Disclosure Leads and help them train and prepare … This tool can help assess readiness and attitudes of potential staff members to serve as Disclosure Leads … The Disclosure Checklist is a reference tool that provides Disclosure Leads and staff with the basic

359. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Slide 3 Say: Response and Disclosure is led by a team of trained Disclosure Leads. … The organization should identify a team of Disclosure Leads who can develop the knowledge, skills, and … Several tools in the toolkit can be used to identify Disclosure Leads and help them train and prepare … This tool can help assess readiness and attitudes of potential staff members to serve as Disclosure Leads … The Disclosure Checklist is a reference tool that provides Disclosure Leads and staff with the basic

360. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Slide 3 Say: Response and Disclosure is led by a team of trained Disclosure Leads. … The organization should identify a team of Disclosure Leads who can develop the knowledge, skills, and … Several tools in the toolkit can be used to identify Disclosure Leads and help them train and prepare … This tool can help assess readiness and attitudes of potential staff members to serve as Disclosure Leads … The Disclosure Checklist is a reference tool that provides Disclosure Leads and staff with the basic