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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - occurs with little warning and requires a complex set of resuscitative actions to be instituted within minutes … Studies have consistently shown that survival from VF decreases profoundly over the course of minutes
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - Busy PCPs who may only have 15 minutes for a visit cannot be expected to complete a detailed neurologic … Yet, a brief, focused, high-yield exam can be performed in 5 minutes and help avoid missing
key diagnoses
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - With the patient becoming hypoxic (i.e., oxygen saturation <90%) for about 5 minutes, he called
for … In summary, this patient had five minutes of low oxygen saturations and lost two front incisors during
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - Thirty minutes after discharge, the radiologist called the care team to alert them to the finding of … pneumothorax as a category 1
actionable finding and recommends reporting of those findings, within minutes
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psnet.ahrq.gov/node/60857/psn-pdf
August 26, 2020 - influenced by patient
comorbidities; persistent digital ischemia has been reported after as few as 20 minutes … for
maintaining a bloodless surgical field.18 These blocks decrease digital perfusion for 10 to 60 minutes
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - Over the next few minutes,
the patient's blood pressure skyrocketed to 250/135 mm Hg.
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psnet.ahrq.gov/issue/extra-dose-safety
June 16, 2019 - Newspaper/Magazine Article
An extra dose of safety.
Citation Text:
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
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For…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - Because she did not wish to be intubated, she expired approximately 30 minutes after arrival to the floor
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psnet.ahrq.gov/node/837958/psn-pdf
December 01, 2021 - Offload Time (APOT) by the California Health and Safety Code, wall
time is defined as the “time (in minutes … recommended “zero tolerance” for ambulance transfer delays and established a national standard of 15
minutes
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - right patient will take a couple
of telephone calls, and so might delay the start of the case by 10 minutes … Ten minutes later, she releases the patient to the transporter.
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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - Focuses on harm, but
includes errors as well• Allows sampling
strategy• Relatively efficient: 20 minutes … good
sensitivity
• Requires training• Resource
intensive: IHI recommends 20
charts per month at 20 minutes
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - low-frequency phased array probe—these techniques can be 93%–96%
accurate, reduce confirmation time from 70–80 minutes … (for chest radiograph) to 10 minutes using
ultrasound, and allow for immediate identification of pneumothorax
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - After
about 30 minutes, the patient's nurse came back from break and found him to be lethargic. … The patient was
started on dextrose 10% IV solution and blood glucose levels were monitored every 15 minutes
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - B back immediately, about 20 minutes after the previous call. Unfortunately, Mrs. … B and her children were distraught after experiencing 20 minutes of thinking that their beloved husband
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Call me if they don't respond in 15 minutes." … Could you call me in the next 5–10 minutes?"
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psnet.ahrq.gov/node/39714/psn-pdf
April 14, 2011 - US public opinion regarding proposed limits on resident
physician work hours.
April 14, 2011
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician
work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
https://psnet.ahrq.gov/issue/us-public-opinion-regarding-pr…
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psnet.ahrq.gov/issue/practitioners-agree-medication-reconciliation-value-frustration-and-difficulties-abound
August 09, 2023 - Newspaper/Magazine Article
Practitioners agree on medication reconciliation value, but frustration and difficulties abound.
Citation Text:
Practitioners agree on medication reconciliation value, but frustration and difficulties abound. ISMP Medication Safety Alert! Acute care edition. Ju…
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psnet.ahrq.gov/issue/shining-glaring-light-surgery-technology-records-every-move-aims-improve-safety
January 29, 2020 - Newspaper/Magazine Article
Shining a glaring light on surgery: technology that records every move aims to improve safety.
Citation Text:
Shining a glaring light on surgery: technology that records every move aims to improve safety. Freyer FJ. Boston Globe. January 13, 2024.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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