-
psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
-
psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…
-
psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
-
psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
-
psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
-
psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix
Leo A. Gordon, MD | September 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…
-
psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
-
psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - aerosol transport and that
aerosolized SARS-CoV-2 particles can remain suspended in the air for several hours … and patients with new,
unmet urgent needs, and as a result, may consider extending their practice hours
-
psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - When employees believe that they should just show up at work, do their 8 hours, and then leave—because … The waiting time went down by about 4 hours and the experience of the clinicians also improved markedly
-
psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - and there is a concern about a low-grade fever, or one out of four blood cultures is positive at 48 hours … It may take a couple of hours to get another PICC in a patient, and we don't like finding out on a Monday
-
psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - When employees believe that they should just show up at work, do their 8 hours, and then leave—because … The waiting time went down by about 4 hours and the experience of the clinicians also improved markedly
-
psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - And then, we supported the nurse when they do their follow-up call about 24 hours later. … We had a couple of our students who were research assistants spent about 200 hours in the ED pre-COVID
-
psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - diagnosis of their patient populations,
patient case mix index (CMI), duration of patient ventilation hours
-
psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - inadequate staffing, poor incentive systems, hierarchical systems, competition for cases, long work hours
-
psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - After 2 hours of surgery, the vascular surgeon decided that they would need to use a vein from the patient's
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - from venous sources injured during the tracheostomy procedure usually presents within the first 48 hours
-
psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - At the time of ward admission (4 hours after presentation), the patient remained hemodynamically stable
-
psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - With the next shift change, a new team took over and after a few hours, the IR nurse called asking for
-
psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - pneumothorax
Testicular/ovarian torsion
Unexplained pneumoperitoneum
Unstable spine fracture
Within Hours
-
psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - With increased specialization and reductions in trainee work hours, first in Europe and more recently