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psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety
September 07, 2022 - Newspaper/Magazine Article
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.
Citation Text:
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. ISMP Medication Safety Alert! Acut…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - temporary IDs were quickly switched to the true IDs, but the timing for such corrections can range from 30 minute
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - His vital signs now demonstrated significant instability, with a heart rate of 144 beats per minute,
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - of hospital medicine was the need for PCPs to carry full panels of patients, seeing
them in 15–20 minute
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - She was given IV fluids for
tachycardia (heart rate 140 beats per minute [bpm]) and hypotension, with
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Fetal heart tones were about 130 per minute.
Routine prenatal care was planned.
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psnet.ahrq.gov/node/49629/psn-pdf
June 01, 2011 - Whoever assumes care of the patient—even during a 10-minute
break—needs to have a clear understanding
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - to check their medications, ask providers to disinfect their hands, and
notify clinicians of last-minute
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - 2022
Guidelines for timely medication administration: response to the CMS "30-minute
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - exacerbation of symptoms of hyperthyroidism; severe thyrotoxicosis; [may be] marked by rapid pulse (140–170/minute
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psnet.ahrq.gov/web-mm/weak-response
February 24, 2011 - He was found to be in atrial fibrillation with a ventricular response of 120 beats per minute.
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - Her vital signs in the ED were notable for a heart rate in the 90s and hypoxia requiring 2 liters/minute … lactate rose to 4.7 mmol/L (normal < 2.0 mmol/L) and her oxygen requirement increased to 3-4 liters/minute
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar …
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - cases with severe neurologic symptoms, such as seizures or coma, the panel recommended use of a 10-minute
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/issue/fda-advise-err-medication-errors-associated-cerebyx
May 02, 2018 - Newspaper/Magazine Article
FDA Advise-ERR: medication errors associated with Cerebyx.
Citation Text:
FDA Advise-ERR: medication errors associated with Cerebyx. ISMP Medication Safety Alert! Acute Care Edition. April 10, 2008;13:1-2.
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