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psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Afterward, the patient became unresponsive due to a cardiac arrest during transport and a Code Blue was
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - She rapidly worsened and had a respiratory arrest; a code blue was called.
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - pumps" (infusion pump that alerts operators when it is infusing
outside of pre-configured limits), bar-code
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - and job satisfaction, in which teams of two work together with one dictating while the other writes code
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - https://psnet.ahrq.gov//#references
required by state laws to be encrypted (data is converted into code
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - A code blue was called for opioid and benzodiazepine overdose.
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - The patient soon became pulseless, a code was called, and the patient expired after
failed resuscitative
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - For patient X in room Y, the patient's code status is .
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - support therapy in a Veteran Affairs health care system: use of medication administration record and bar code
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - For example, assessing data related to bar code overrides can identify areas of targeted improvement
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - document all instances of medication administration as required by their state’s Nurse Practice Act and Code
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - June 16, 2019
Development and implementation of a subcutaneous insulin pen label bar code
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - care units or operating rooms) as well as on high-risk clinical teams (such as rapid response teams, code
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - March 13, 2013
WebM&M Cases
Code Blue—Where To?
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - in the ED waiting for the OR, the patient became
unresponsive and pulseless
• The team called a code
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
-
psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…