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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - Similarly, maybe we could walk into an operating theatre and say, there are 30 sources of risk there,
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - , 2022
Impact of critical event checklists on anaesthetist performance in simulated operating
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psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
January 01, 2009 - For example, when a harmful error has taken place in the operating room and a second procedure is required
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - While the number of dentists still operating private practices is in decline, in 2015 80% of dentists
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - Stephen Hoy : I am Stephen Hoy, the Chief Operating Officer, and I have recently been working in the
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psnet.ahrq.gov/node/60610/psn-pdf
June 24, 2020 - may have assumed a young person would rather not have surgical scars or be physically exposed in the
operating
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - In addition to optimizing the ACD, standard operating procedures should be in place to independently
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - Stephen Hines: We recognize that many healthcare teams may be operating partially or entirely virtually
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - Now you're operating in a busy ecosystem; a good
number of entities are now rating hospitals, like US
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - families that the patient is “not a surgical candidate” even in cases when it is clear that death
on the operating
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - This huddle includes at least one provider from obstetrics, anesthesia,
nursing, and the operating room
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - What they have created, though, is a culture and an operating style that
sensitizes every single individual
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - hypotensive and tachycardic with continued vaginal bleeding, so the decision was made to return to the operating
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - The high 5s assuring medication accuracy at transitions in care: Medication reconciliation standard operating
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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Downloa…
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - The Role of the FDA in Ensuring Device Safety
May 28, 2020
Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
Introduction
The Food and Drug Administration (FDA) plays a critical role in ensuring the …
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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - Safety Considerations in Building a Point-of-Care
Ultrasound Program
June 1, 2018
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
Perspective
At the American Colle…
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…