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Total Results: 3,178 records

Showing results for "led".

2961. Unintended Consequences of CPOE | PSNet
      psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
      September 01, 2004 - management systems in commercial aviation in the 1990s increased the cognitive demands on pilots and led

2962. Patient as a Team Member in Clinical Care | PSNet
      psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
      March 15, 2025 - found that encouragement from staff, education about patient safety, and comprehensible information all led

2963. Patient Safety Events Involving Opioid Dose Stacking | PSNet
      psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
      July 08, 2022 - opioids via patient-controlled analgesia (PCA) and simultaneously via intravenous push has historically led

2964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33748/psn-pdf
      April 01, 2013 - RW: You led a now famous study that demonstrated no change in at least one way of measuring patient

2965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33686/psn-pdf
      August 01, 2009 - are going to find is that people actually followed the rules and that the rules were bad rules and led

2966. In Conversation With… Sidney Dekker, MA, MSc, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
      February 26, 2025 - And that led to fascinating divergences between what the pilots thought they told the airplane to do

2967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33752/psn-pdf
      August 01, 2013 - Ten years from now, people will probably still say that the projects that led to checklists being the

2968. The Forgotten Turn | PSNet
      psnet.ahrq.gov/web-mm/forgotten-turn
      August 01, 2018 - Furthermore, it became clear the patient had not been moved in her bed since her time in the ED, which likely led

2969. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50841/psn-pdf
      January 29, 2020 - errors was the wrong blood reaching the patient’s bedside, a high risk near-miss event that may have led

2970. Technology as a Tool for Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
      April 26, 2023 - alerts were overridden, only 9.3% of those were inappropriately overridden, and very few overrides led

2971. Implementation of Patient Safety Projects | PSNet
      psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
      September 15, 2025 - This systematic review examined which aspects of new safety practice implementations led to actual improvement

2972. Maternal Safety | PSNet
      psnet.ahrq.gov/curated-library/maternal-safety
      January 31, 2024 - collaborative, this program divided participating health systems into groups of six to eight hospitals, led

2973. Crushing Chest Pain: A Missed Opportunity | PSNet
      psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
      February 01, 2007 - What led to the fatal diagnostic error in this case?

2974. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
      January 01, 2023 - during general anesthesia.28 • It is possible that her obesity, and perhaps other social factors, led

2975. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - Simple checklists used at the time of ordering for self-check might have led the oncologist to identify

2976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33776/psn-pdf
      January 01, 2015 - Look at what's going on in General Motors in response to ignition switch problems that have led to deaths

2977. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - While this has led to a gradual shift toward the use of process measures (what was done) instead of outcomes

2978. Isolated Clot, Real Error | PSNet
      psnet.ahrq.gov/web-mm/isolated-clot-real-error
      December 01, 2013 - low-risk patients can be managed with simple clinical surveillance.( 3 ) In this case, several errors led

2979. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866618/psn-pdf
      December 31, 2024 - Several errors led to the poor outcome, stemming from an initial failure to recognize pseudohyperkalemia

2980. Postdischarge Follow-Up Phone Call | PSNet
      psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
      May 19, 2021 - large telephone follow-up program at a tertiary care medical center with medical–surgical patients led