-
psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
-
psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX …
-
psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
-
psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss
June 15, 2024 - Commentary
Wrong site surgery: a critical incident analysis of a near miss.
Citation Text:
Tichanow S. Wrong site surgery: A critical incident analysis of a near miss. J Perioper Pract. 2016;26(1-2):11-5.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 XML End…
-
psnet.ahrq.gov/issue/when-medical-students-make-errors
March 08, 2017 - Newspaper/Magazine Article
When medical students make errors.
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
May 28, 2014
View more articles from the same authors.
This newspa…
-
psnet.ahrq.gov/issue/sentinel-event-alert-67-preserving-patient-safety-after-cyberattack
March 13, 2024 - Sentinel Event Alerts
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack.
Citation Text:
Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack. Jt Comm J Qual Patient Saf. 2023;49(12):724-729. doi:10.1016/j.jcjq.2023.07.006.
Copy Citation
Format…
-
psnet.ahrq.gov/issue/patientfamily-crisis-hotline
December 02, 2020 - Multi-use Website
Patient/Family Crisis Hotline.
Citation Text:
Patient/Family Crisis Hotline. Sorry Works!
Copy Citation
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
…
-
psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
October 24, 2018 - April 12, 2019
Root cause analyses of reported adverse events occurring during gastrointestinal
-
psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
August 02, 2015 - April 12, 2019
Root cause analyses of reported adverse events occurring during gastrointestinal
-
psnet.ahrq.gov/issue/supratherapeutic-dosing-acetaminophen-among-hospitalized-patients
February 14, 2017 - October 30, 2010
Medication errors occurring with the use of bar-code administration
-
psnet.ahrq.gov/issue/improving-health-care-quality-and-patient-safety-through-peer-peer-assessment-demonstration
March 14, 2018 - September 29, 2021
Systematic evaluation of errors occurring during the preparation of
-
psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
June 01, 1989 - April 22, 2015
Baccalaureate nursing students' accounts of medical mistakes occurring
-
psnet.ahrq.gov/issue/can-asking-emergency-physicians-whether-or-not-they-would-have-done-something-differently
July 01, 2016 - January 26, 2022
Analysis of risk factors for patient safety events occurring in the
-
psnet.ahrq.gov/issue/missed-serious-neurologic-conditions-emergency-department-patients-discharged-nonspecific
April 08, 2018 - March 19, 2019
Analysis of risk factors for patient safety events occurring in the emergency
-
psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - The Commentary
Background Errors in laboratory services encompass a number of problems occurring outside … physicians often attribute to errors inside the laboratory, are actually the result
of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside
-
psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - warrants close assessment and aggressive management by nursing staff to prevent serious breakdown from occurring … constitute nearly 10% of Medicare admissions to acute care, with nearly 40% of these hospitalizations occurring … taking high risk medications such as anticoagulants are monitored daily to assure no adverse events are occurring
-
psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - The most recent analysis described 46
deaths and 263 procedure-related complications occurring from … references
https://psnet.ahrq.gov//#references
Quality improvement strategies to prevent these events from occurring
-
psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - In a recent study of adverse events occurring on
mental health units in the Veterans Health Administration … Adverse events occurring on VHA mental health units. Gen
Hosp Psychiatry. 2018;50:63-68.
-
psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - downside of first-order problem solving is lack of
communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare,
occurring in only 7% of the situations
-
psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - The Commentary
Background Errors in laboratory services encompass a number of problems occurring outside … often attribute to errors inside the laboratory, are actually the result of preanalytic problems occurring … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside