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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - assistance involve critical or potentially critical injury or illness like trauma, altered sensorium, breathing … you ask them, "Does he know what he would want in the event that his heart stopped or that he stopped breathing … January 17, 2018
Paramedic intubation errors: isolated events or symptoms of larger problems
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - One team member should be dedicated to titrating sedative medication and monitoring the patient’s breathing … Use online registers for anesthetic problems
Some health care systems offer online anesthetic problem … registers to help prevent potentially recurring anesthesia-related problems. 18 These online registers … An online register for anesthesia problems can be helpful—especially when the patient changes health … regionally organized system for facilitated reporting of potentially recurring anaesthetic-related problems
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - Although she was initially stable (without oxygen requirements), her breathing soon became labored, with … assessments and actions made by the outgoing personnel.( 1-2 ) One study reported that sign-out–related problems … patient-days of care.( 3 ) Erroneous actions stemming from shift changes have caused a wide variety of problems … I have assessed the patient personally, and vital signs are BP , pulse , respiration , and temperature … I am concerned about the respiration because it is . The patient's mental status is .
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - When respiration is depressed by opiates, as evidenced by miotic, unresponsive pupils, naloxone (Narcan … drug to central circulation Maintain normocarbia or slight hypercarbia Increase O2 flow to breathing
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - cardiac arrest in the patient, and the usual resuscitative measures of promoting a clear airway, adequate breathing
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - Nevertheless, some problems occurred in the triage and early management of this patient, and they help
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - When oxygen is absent, anaerobic respiration very rapidly leads to lactic acidosis and cardiac arrest … FIO2 when using low fresh gas flow Using low fresh gas flow may produce a hypoxic gas mixture in the breathing … This new technology effectively eliminates the risk of a hypoxic gas mixture in the breathing system … country When using low flow anesthesia clinicians need to ensure adequate oxygen concentration in the breathing
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Experienced clinicians have an extensive knowledge base, replete with exemplars of problems, symptom … decision-making to deliberate consideration, and "fast and frugal" was the clear winner, especially for complex problems … Most patient problems are very familiar to clinicians.
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - and contingency planning includes statements that assist the cross-coverage in managing anticipated problems … are expected to verbally signout administrative information, a brief history, tasks, and anticipated problems
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty breathing … brings up several issues related to medication safety in women who are, or could be, pregnant—including problems
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - Trask, RN, Kathleen M Carlsen, PA, Brooks T Kuhn, MD
Background
This case exemplifies the multiple problems … The patient in this case experienced cascading problems that ultimately led to clinical decompensation … This commentary will discuss the various components of this case that contributed to the problems that … components: A ssess, prevent, and manage pain; B oth spontaneous awakening trials (SAT) and spontaneous breathing … clinicians’ ability to observe patients, which may cause safety issues. 20 Methods to mitigate these problems
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - I also research some of the pressing problems around patient experience,
patient-centered care, burnout … They intentionally deferred to the expertise of the respiratory therapists in all
things breathing, … failure to think thoroughly enough about
the complex, organizational determinants that condition the problems … ” we have to work on how we are going to marshal tools in a high
reliability-oriented way to solve problems
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Misconnection Leading to Arterial Thrombosis
Citation Text:
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Radiograph Interpretation Error
(22)
Discontinuities, Gaps, and Hand-Off Problems … She heard the conversation among the surgical team members and felt that the breathing tube was pushed
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
Citation Text:
Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - Respiration. 1992;59:215-20.[ go to PubMed ] 4. Colt HG, Brewer N, Barbur E. … Requirements Patient Care Compassionate, appropriate, and effective treatment of health problems
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - He reported no major medical problems and no history of snoring. … maintained under anesthesia, the anesthesia either needs to be rapidly reversed to allow for spontaneous respiration … required for excision of the pilonidal sinus leads to atelectasis and hypoxemia in a spontaneously breathing
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - The patient also felt that the breathing tube was pushed up against the inside of her throat, impeding … Changes in respiration are also a sign of depth of anesthesia but can only be assessed if the patient
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - a time, the strategic changes are often subtle, and their effect may go unnoticed, causing no other problems … Although it may seem easier to concentrate on the human contributions to errors, the root causes of the problems