-
psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - the morning dose was scheduled to be given at 6 AM, but the patient was scheduled to leave for the operating … room before 6 AM, so she gave the dose early, at 4 AM.
-
psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - WebM&M Cases
If You Say So: Taking a Syringe at Face Value in the Operating … Room
June 1, 2019
WebM&M Cases
Unexpected
-
psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - This operating room (OR) case also involved a look-alike packaging issue (Figure).
-
psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
July 01, 2011 - Fumbled Handoff
March 1, 2004
View More
See More About The Topic
Operating … Room
Health Care Providers
Information Professionals
Surgery
Discontinuities, Gaps, and
-
psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - the morning
dose was scheduled to be given at 6 AM, but the patient was scheduled to leave for the operating … room
before 6 AM, so she gave the dose early, at 4 AM.
-
psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - hematoma with mass
effect on the brain and surrounding cerebral edema
• Patient was transported to the operating … room and the
neurosurgeon performed an emergent craniotomy and placed
an external ventricular drain
-
psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - their hands, so this must be a ritual similar to the ritualistic surgical scrub prior to entering the
operating … room.
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Virtual reality training improves operating room performance: results of a randomized, double-blinded
-
psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - as prohibiting the use of neuromuscular blocking agents outside of intensive care units [ICUs]
and operating … room settings).
-
psnet.ahrq.gov/node/864868/psn-pdf
March 27, 2024 - H is transferred to the operating room for repair
of multiple fractures. Subsequently, Mr.
-
psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - WebM&M Cases
If You Say So: Taking a Syringe at Face Value in the Operating … Room
June 1, 2019
Annual Perspective
Rethinking
-
psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - They took her to the operating room (OR) together for suspected necrotizing fasciitis.
-
psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - 2018
View More
See More About The Topic
Outpatient Surgery
Operating … Room
Anesthesiology
Surgery
Anesthesia Nursing
View More
-
psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
-
psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
-
psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
-
psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - PowerPoint Presentation
Spotlight
Privacy or Safety?
1
This presentation is based on the July/August 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
-
psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - An Outpatient 'Zebra'
Citation Text:
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
-
psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - the patient was transferred to a motorized gurney to extubate him in a sitting position because
the operating … room (OR) table was too narrow.