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81. Implementing the SPPC-II Teamwork Toolkit (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation-speaker-notes.pdf
    July 01, 2023 - tactics and planning for the SPPC‐II Teamwork Toolkit implementation. 1 Hospital AIM Team Leads … providing your organizational leadership with an overview of your plan. 2 Hospital AIM Team Leads … We will now be working on the last four steps. 4 Hospital AIM Team Leads SPPC‐II ✓ Step … 10 Hospital AIM Team Leads SPPC‐II Step 3A: Establish a Roll‐out Plan with timeframe Key … 21 Hospital AIM Team Leads SPPC‐II Step 6.

82. Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. | PSNet
    psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea-involuntary-manslaughter
    May 07, 2018 - Newspaper/Magazine Article Failed check system for chemotherapy leads to pharmacist's … Citation Text: Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary … Cite Citation Citation Text: Failed check system for chemotherapy leads … May 5, 2018 Misprogramming PCA concentration leads to dosing errors.

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60309/psn-pdf
    May 06, 2020 - COVID-19 leads to increased need for dialysis machines. May 6, 2020 Mosley T. Here & Now. … https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines Comorbidities can result … https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines https://psnet.ahrq.gov/issue

84. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38619/psn-pdf
    May 07, 2018 - Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter … https://psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea- involuntary-manslaughter … https://psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea-involuntary-manslaughter … https://psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea-involuntary-manslaughter

85. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 … https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error … https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error

87. Procedure Manual Section 7. Formulation of Task Force Recommendations | United States Preventive Services Taskforce
    www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-7-formulation-task-force-recommendations
    June 21, 2025 - After full consideration and decision on both certainty and magnitude of net benefit, the topic leads … , the leads identify any grade changes and discuss the rationale for proposed grade change. … The leads refine the draft recommendation with final language before it is released for public comment … At that point, any new evidence is reviewed by the topic leads with help from AHRQ and the appropriate … The topic leads present their motion and any important new evidence to the full Task Force (most often

88. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44239/psn-pdf
    September 29, 2017 - When medical care leads to harm—difficulty finding words: a teachable moment. … When medical care leads to harm- difficulty finding words: a teachable moment. … https://psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment … https://psnet.ahrq.gov/issue/when-medical-care-leads-harm-difficulty-finding-words-teachable-moment https

89. Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error | PSNet
    psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error
    February 10, 2021 - Magazine Article Leaving a discontinued FentaNYL infusion attached to the patient leads … tragic error Citation Text: Leaving a discontinued FentaNYL infusion attached to the patient leads … Citation Citation Text: Leaving a discontinued FentaNYL infusion attached to the patient leads

90. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Mazur (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-unc-webcast-mazur.pdf
    June 02, 2025 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … U N C H E A L T H C A R E Implementation of an Event Reporting and Learning System Leads … rewards & recognition, • Lead by example Implementation of an Event Reporting and Learning System Leads

91. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45452/psn-pdf
    August 24, 2016 - Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared … https://psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-epinephrine-auto-injectors- leads-error-prone-use … https://psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-epinephrine-auto-injectors-leads-error-prone-use … https://psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-epinephrine-auto-injectors-leads-error-prone-use

92. 165-Cusp-Monthly-Meeting-Agenda (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/165-cusp-monthly-meeting-agenda.docx
    June 02, 2025 - Agenda Overview: CUSP Champion or designated team leads summarizes the agenda. … State of Our Safety Union: CUSP Champion or designated team leads/guest speakers may share dashboard … Status of Safety Efforts: CUSP Champion or designated team leads share status of current safety projects

93. Appendix B: Meeting Attendees’ Biographical Sketches | Agency for Healthcare Research and Quality
    www.ahrq.gov/evidencenow/projects/state/meeting-summary-cooperatives/appendix-b.html
    October 01, 2024 - Thought Leaders Porcha Carter  - In the role of Director of Community Partnerships, Porcha leads … Donohue leads the Data Coordinating Center, conducts research to improve the quality and equity of care … In this role, she also leads the California Quality Collaborative (CQC), a multi-stakeholder healthcare … As the Chief Informatics Officer, Andrew leads AllianceChicago’s strategy related to developing health … In these roles, she leads initiatives to generate and/or translate data for policymakers to inform the

94. 068-Cusp-Monthly-Meeting-Agenda (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/068-cusp-monthly-meeting-agenda.docx
    April 01, 2025 - Agenda Overview: The CUSP Champion or designated team leads summarize the agenda. … Safety Update: The CUSP Champion or designated team leads/guest speakers may share dashboard data, harm … Status of Safety Efforts: The CUSP Champion or designated team leads share the status of current safety

95. Parkland knee surgery done by doctor in training leads to amputation, questions. | PSNet
    psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions
    August 11, 2010 - Newspaper/Magazine Article Parkland knee surgery done by doctor in training leads … Citation Text: Parkland knee surgery done by doctor in training leads to amputation, questions. … Cite Citation Citation Text: Parkland knee surgery done by doctor in training leads

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38051/psn-pdf
    May 05, 2018 - Misprogramming PCA concentration leads to dosing errors. … https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes … https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40055/psn-pdf
    December 01, 2010 - Parkland knee surgery done by doctor in training leads to amputation, questions. … https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions This … https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions https

98. The absence of a drug–disease interaction alert leads to a child's death. | PSNet
    psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
    July 08, 2015 - Newspaper/Magazine Article The absence of a drug–disease interaction alert leads … Citation Text: The absence of a drug–disease interaction alert leads to a child's death. … Cite Citation Citation Text: The absence of a drug–disease interaction alert leads

99. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
    psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
    July 23, 2024 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39825/psn-pdf
     June 10, 2018 - Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. … https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error … https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error