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psnet.ahrq.gov/print/pdf/node/73848
July 01, 2022 - comprehensive safety program, which included teamwork training, additional staffing
and reduction of work hours … comprehensive safety program, which included teamwork training, additional staffing
and reduction of work hours
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - The patient was transferred to a
general surgical recovery bed, with vital signs ordered every 4 hours … Over the next 14 hours, the patient’s
blood pressure remained at or below 90/60, and he was described
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - Effect of reducing interns' work hours on serious medical errors in intensive care units. … And it's now fairly clear that in the last 3 or 4 hours of the night shift, the emergency physician is … It's extremely difficult to make good decisions in the last 3 or 4 hours of the night shift.
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - Privacy Gone Awry
May 1, 2004
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/privacy-gone-awry
The Case
A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy.
Preoperatively, she had an upper respiratory infection, but was eating…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - Spotlight
Spotlight
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
*
Source and Credits
This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Olle ten C…
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - Effect of reducing interns' work hours on serious
medical errors in intensive care units.
-
psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - matter what monitoring we pull out of or put back into the system, if a woman has been pushing for 3 hours … , then 4 hours, then 5 hours when it's 2:00 AM, there's no objective way of knowing how big an infant's
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - .): Code Status Confusion
A few hours after admission, the patient had sudden respiratory failure leading
-
psnet.ahrq.gov/node/33802/psn-pdf
February 01, 2016 - medical school applications are on the rise) and
encouraging fully trained physicians to spend more hours
-
psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - When a clinician is not immediately available—for example, after hours—patients may
have to rely on
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - planning on hospital admission showed a dramatic reduction in medication errors within the first 24 hours
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - For example, many injuries are discovered in a delayed evaluation after 24-48 hours in the hospital,
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psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
September 01, 2004 - dexamethasone, was anticipated to furnish the stat 10 mg dose and the second 8 mg dose to be given 6 hours
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - As opposed to complete encounters that may last hours, extraction of brief but most critical video segments–especially
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Duty hours for resident physicians—tough choices for teaching hospitals.
-
psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - The patient died several hours later.
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Duty hours for resident physicians—tough choices for teaching hospitals.