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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Ci…
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psnet.ahrq.gov/node/837958/psn-pdf
December 01, 2021 - The patient was admitted to the orthopedic inpatient service and taken to the operating room on hospital
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - In the operating room, where a lot of these issues come up, a steady background noise might actually
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - WebM&M Cases
Medication Handling and Compounding Errors in the Operating … Room.
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - orthopedic resident notified the cross-covering medicine resident that the patient would be taken to the operating … room (OR) the following day.
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - The patient was admitted to the orthopedic inpatient service and taken to the operating room on hospital
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - On day 11, he was taken to the operating room for video-assisted thoracoscopic (VATS) decortication of … : Fluid administration errors in the operating room.
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
View more articles from the same authors.
Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
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psnet.ahrq.gov/node/33762/psn-pdf
March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH
March 1, 2014
In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College
Healthcare NHS …
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - Adapting to new technology in the operating room.
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - July 3, 2014
Video technology to advance safety in the operating room and perioperative
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - verbal signouts are often conducted in interrupted environments, such as at the nurses'
station, in the operating … room, amidst answering pages, etc.
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - While being prepped on the operating room table several hours later, the patient developed asystole,
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - WebM&M Cases
If You Say So: Taking a Syringe at Face Value in the Operating … Room
June 1, 2019
WebM&M Cases
Near Miss With
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - Following an RCA of this event, the operating room (OR) manager was instructed to evaluate all OR supplies
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - and placing high priority “STAT” tests in central laboratories located near emergency departments, operating … rooms, and intensive care units, while slower or more esoteric tests may be based in more distant satellite
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…