-
psnet.ahrq.gov/issue/5th-national-audit-project-nap5-accidental-awareness-during-general-anaesthesia-patient
October 01, 2014 - longer-term harm were prevalent in such incidents despite their short time duration (most lasted less than 5 minutes
-
psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - Upon arrival minutes later, they found the patient apneic and pulseless. … After minutes of trying to determine the cause, it was discovered that the mask had been attached to … code blue team typically arrives to these locations well past the recommended T defib benchmark of 3 minutes
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psnet.ahrq.gov/issue/start-year-right-addressing-these-top-10-medication-safety-concerns-2021
April 20, 2022 - February 23, 2022
There's more to the 60 Minutes story on heparin errors.
-
psnet.ahrq.gov/issue/building-culture-safety-ophthalmology
March 14, 2022 - December 22, 2018
How one hospital improved patient safety in 10 minutes a day.
-
psnet.ahrq.gov/issue/start-year-right-preventing-these-top-10-medication-errors-and-hazards-2020
February 09, 2022 - April 20, 2022
There's more to the 60 Minutes story on heparin errors.
-
psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
May 01, 2019 - You may only have 12 minutes with a patient, yet you've initiated all the care that patient needs to … the back of the ambulance with a patient who's trying desperately to go to God, and you only have 12 minutes … that I've figured out that this is a STEMI, I'm driving past a local ED, and I have to drive 37 more minutes … And it's going to take you 5 minutes of discussion to even have any chance of sorting it out. … I went to the electronic medical record, and within 5 minutes of receiving the patient, I had their patient
-
psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - You may only have 12 minutes with a patient, yet you've initiated all the care that patient needs to … the back of the ambulance with a patient who's trying desperately to go to God, and you only have 12 minutes … that I've figured out that this is a STEMI, I'm driving past a local ED, and I have to drive 37 more minutes … And it's going to take you 5 minutes of discussion to even have any chance of sorting it out. … I went to the electronic medical record, and within 5 minutes of receiving the patient, I had their patient
-
psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - delayed-evaluation-abdominal-pain-elderly-patient
vomit blood a few moments later, was transferred to an inpatient room within 30 minutes … , and died 30
minutes later. … necrosis was eventually identified, yet she was not
moved to a standard ED treatment bed for another 25 minutes … their development, triage assessments were limited in scope and intended to be completed within
10-15 minutes
-
psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Several minutes later, when she re-entered the room of the
leukemia patient, she forgot what she had … Emergency physicians are interrupted, on average,
nearly once every 5 minutes, and, perhaps more concerning
-
psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - shown evidence of Category 2 and 3 abnormalities (moderate-to-severe fetal distress) for at least 90 minutes … Unlike traditional paper tracings where a clinician can quickly scan 30 minutes or more of activity,
-
psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - After about 5 minutes, the anesthesia team noticed that the patient was unresponsive, with shallow breathing … vaporizer to maintain anesthesia (as the administered intravenous agents would typically only last 5–10 minutes
-
psnet.ahrq.gov/issue/medication-administration-discrepancies-persist-despite-electronic-ordering
May 04, 2012 - that inpatient CPOE did not prevent medication administration discrepancies, and delays of nearly 30 minutes
-
psnet.ahrq.gov/issue/multitasking-clinician-decision-making-and-cognitive-demand-during-and-after-team-handoffs
September 15, 2011 - emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes
-
psnet.ahrq.gov/issue/how-master-new-art-training-teamwork-fly
June 28, 2011 - March 3, 2021
How one hospital improved patient safety in 10 minutes a day.
-
psnet.ahrq.gov/issue/anticoagulant-safety-takes-center-stage-2007
May 07, 2018 - May 2, 2018
There's more to the 60 Minutes story on heparin errors.
-
psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
September 09, 2015 - November 8, 2023
How one hospital improved patient safety in 10 minutes a day.
-
psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Active myocardial ischemia
Agitation that required increased sedative administration in the past 30 minutes … and active
range of motion to strengthen the extremities, and assist to a sitting position for 20 minutes
-
psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
March 03, 2021 - March 3, 2021
How one hospital improved patient safety in 10 minutes a day.
-
psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - buildup should be prevented by allowing adequate venting of drapes and by shutting off oxygen 3–5
minutes … atmosphere
Replace oxygen with compressed air or discontinue supplemental
oxygen for a period of time (few minutes … The surgeon must warn the anesthesiologist a few minutes prior to
use of electrocautery.
-
psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - After
completion of the antibiotic course, the CVC was removed and the patient was discharged 30 minutes … Place pressure on the site for 1 to
5 minutes. … Instruct the patient to remain lying
flat for 30 minutes after removal of
the catheter.