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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - the pediatric intensive care physician, but
they were unable to arrive at the child’s bedside for 30 minutes … and 45 minutes, respectively, so the
anesthesiologist ordered blood for an urgent transfusion. … A “code blue” was called and the child was successfully resuscitated after about 20 minutes,
https:/
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - After about two minutes, the patient started to cough up bloody secretions and was administered 100% … Although the patient's saturation was less than 80-88% for at least 10 minutes, he suffered no apparent … impaired ventilation and inadequate brain oxygenation, it can lead to brain damage within just a few minutes
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psnet.ahrq.gov/innovations-video
August 09, 2025 - Learn About the Submit an Innovation Process
PSNet’s Submit an Innovation feature allows organizations to share successfully implemented innovative practices and/or interventions that have resulted in improved patient safety and reduced harm. Watch the video below to learn more about the Submit an Innovation process…
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psnet.ahrq.gov/submit-case
August 10, 2025 - The Submit a Case Process
PSNet’s Submit a Case feature allows health care professionals to submit de-identified cases that feature patient safety and health care quality issues to PSNet’s WebM&M educational journal. Watch the video below to learn more about the Submit a Case process.
Submit Your Case
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - cord process
18
18
High-Yield Screening Exam in Neurology
Busy providers who may only have 15 minutes … to complete a detailed neurologic examination
A brief, focused, high-yield exam can be performed in minutes
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - to arrange transport and was told someone would be down to
transport the patient to surgery in 30 minutes … , there was a substantial delay in OR readiness: although her condition was critical, more than 60
minutes … Nationally, only 40% of
patients are seen within 15 minutes of arrival, and over 1% of patients leave
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Approximately 45 minutes later, the unit clerk called the infant's
bedside nurse to report that the … case
of an unstable infant patient believed to be in significant respiratory distress, waiting 45 minutes … The patient has been on oxygen
for minutes. The oximeter is reading .
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - The pain woke him from sleep, radiated to the left shoulder, and lasted about 15 minutes before spontaneously … risk factors include retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5-15 minutes … , initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within minutes
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psnet.ahrq.gov/innovation/catching-those-who-fall-through-cracks-integrating-follow-process-emergency-department
September 09, 2020 - The system also has a failsafe in place; if the alert is not acknowledged within 60 minutes, the hospital
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psnet.ahrq.gov/issue/implementation-standardized-dosing-units-iv-medications
May 11, 2014 - Study
Implementation of standardized dosing units for I.V. medications.
Citation Text:
Jung B, Couldry R, Wilkinson S, et al. Implementation of standardized dosing units for i.v. medications. Am J Health Syst Pharm. 2014;71(24):2153-8. doi:10.2146/ajhp140046.
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Format: …
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - My joke is that if you tell your wife, just 5 more minutes and I'll finish this email—you end up going … downstairs 17 minutes later, which is pi plus 3x longer. … they're coming in with this, that, and the other thing—we're wrinkling our eyebrows and we have like 5 minutes
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - I'll be there in 5 minutes." … And in the 5 minutes that it took for her to walk to my office, which is adjacent to the Medical Center … What does it feel like to be a patient or a family member in a room where these are going off every 7 minutes … But for somebody who's in chronic atrial fib, we don't need to know every 5 minutes that the patient … example, a prompt could come up indicating that this patient's heart rate has averaged 135 for the last 5 minutes
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - I'll be there in 5 minutes." … And in the 5 minutes that it took for her to walk to my office, which is adjacent to the Medical Center … What does it feel like to be a patient or a family member in a room where these are going off every 7 minutes … But for somebody who's in chronic atrial fib, we don't need to know every 5 minutes that the patient … example, a prompt could come up indicating that this patient's heart rate has averaged 135 for the last 5 minutes
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psnet.ahrq.gov/issue/impact-barcode-medication-administration-technology-how-nurses-spend-their-time-providing
January 09, 2008 - Study
Impact of barcode medication administration technology on how nurses spend their time providing patient care.
Citation Text:
Poon EG, Keohane CA, Bane A, et al. Impact of Barcode Medication Administration Technology on How Nurses Spend Their Time Providing Patient Care. JONA: The…
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psnet.ahrq.gov/issue/effects-technological-interventions-safety-medication-use-system
May 11, 2016 - Study
Effects of technological interventions on the safety of a medication-use system.
Citation Text:
Skibinski K, White BA, Lin LI-K, et al. Effects of technological interventions on the safety of a medication-use system. Am J Health Syst Pharm. 2007;64(1):90-6.
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Fo…
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - 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,
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - Within 30 minutes of his arrival in the ICU, a second patient was transferred from the overflowing emergency … Approximately 5 minutes later, the patient care assistant arrived at the COPD patient's bathroom and
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psnet.ahrq.gov/personalization
Learn About PSNet New User Account Registration
Learn more about how to register and create your profile with our personalization options on PSNet.
Audio-Described Version (1 minute, 27 seconds)
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - Approximately 40 minutes later (1730), the triage nurse noted the patient was missing from the gurney … Eight minutes later the patient was found by an Environmental Services staff member
in a bathroom in … An MHW completes a safety check on each assigned
patient every 15-20 minutes.
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psnet.ahrq.gov/issue/association-between-measured-teamwork-and-medical-errors-observational-study-prehospital-care
May 18, 2022 - Study
Association between measured teamwork and medical errors: an observational study of prehospital care in the USA
Citation Text:
Herzberg S, Hansen M, Schoonover A, et al. Association between measured teamwork and medical errors: an observational study of prehospital care in the USA.…