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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - of The Joint Commission's understanding of health care with high reliability organizational learning led
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - The suitability of PICC lines for such a broad range of clinical situations has led to highly variable
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
March 29, 2023 - Overcrowding in the ED , with boarding of admitted patients, led to inability to room and appropriately
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Although death was averted, it seems quite evident that earlier investigation and intervention might have led
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - errors was the wrong blood reaching the patient’s bedside, a high risk near-miss event that may have led
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - systems-based model for evaluating adverse events, we can see how the holes or gaps in
care aligned and led
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Vermont Blueprint for Health leaders to include the program in its application to CMS, which ultimately led
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - I believe this work in part led to me serving the technical expert panel for this report.
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - unclear A
Working Conditions
Staffing levels, skill mix, and
workload
Nursing shortage has led
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Later, problems with data gathering and information processing led
to a brief delay in recognizing emerging
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - Consultation with infectious disease,
rheumatology, and neurology led to a provisional diagnosis of
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - The impact of a consultant anaesthetist led pre-operative assessment clinic on patients undergoing major
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - intubation
during general anesthesia.28 It is possible that her obesity, and perhaps other social factors, led
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - HSMRs for years, it was whistleblowers among staff and patients who attracted the public attention that led
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - This led to the design of
a prototype operating room that we then implemented in two ambulatory surgery
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - In this case, failure
to follow unit policy in scanning EBM led to administering EBM from the wrong
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - intra-service handoff protocols, to name a few) have not only improved caregiver communication but also led
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - issues and to catch potential problems, such as labs, medication errors, or procedures that would have
led
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - The large increase of these types of treatments has led to the emergence of risks not seen previously
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - In this case, failure to follow unit policy in scanning EBM led to administering EBM from the wrong mother