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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - Sarah Mossburg: With technology, sometimes we find glitches and problems once we start using it. … With the evolution from pen and paper to connected devices, have you run into problems? … For chronic obstructive pulmonary disease (COPD), you can monitor breathing, pulse oximeter numbers, … Historically, these are acute problems that arise where there is illness or injury. … We knew there were hospital capacity problems and a lot of different pressures and stakeholders that
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - The most common causes of errors were hand-off communication problems, staff inattention, knowledge deficit
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - their preference against CPR on their chest, but this is an extreme measure fraught with potential problems
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - Terrified and in restraints, she ultimately managed to self-extubate and clear her breathing passage.
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - Understanding the complexity of medical devices and the problems users may have in following the correct
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - specifically, finding the right balance between achieving adequate analgesia and avoiding adverse effects or problems … medications in the inpatient setting, The Joint Commission recommends performing serial assessments of respiration
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - A full discussion of issues related to the human factors and teamwork problems in this case is beyond … solutions, implement the changes, and then re-evaluate the process to ensure we have not created more problems … or egregious medication misadventures that lead to fatal overdoses—rather than common patient safety problems
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - SPOTLIGHT CASE
Order Interrupted by Text: Multitasking Mishap
Citation Text:
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - and it strikes me that they go so well the vast majority of the time that one can easily think about problems … sounds like you strongly believe that unnecessary C-sections drive a lot of the safety and dignity problems … There are problems of basic social isolation.
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care
Citation Text:
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - In patients with complex medical problems requiring multiple laboratory tests, checklists can act as … Moreover, as humans, although we cannot be perfect in the care we provide to our patients, we can identify problems
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - and it strikes me that they go so well the vast majority of the time that one can easily think about problems … sounds like you strongly believe that unnecessary C-sections drive a lot of the safety and dignity problems … There are problems of basic social isolation.
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - mentioned from the book, the resident thought there was something wrong with this elderly lady who wasn't breathing
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - The things that we asked about was whether or not there were problems during the transfer of patients … We don't just proactively intubate all our patients because they might have some breathing difficulty … Safety Professionals
Emergency Medicine
Emergency Nursing
Discontinuities, Gaps, and Hand-Off Problems
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - they can adopt effective practices such as using preoperative checklists to help identify potential problems … organizations promote mindfulness throughout their structures to help identify, trap, and mitigate potential problems
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - False-positive COVID-19 results: hidden problems and costs.
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - The things that we asked about was whether or not there were problems during the transfer of patients … We don't just proactively intubate all our patients because they might have some breathing difficulty
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - pressure-limiting valve fully closed, the anesthesiologist increases fresh gas flow and squeezes the breathing
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psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
August 31, 2020 - Actually, one of our biggest problems is that we still have a significant, not huge, but a significant