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psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees
June 10, 2020 - Study
Debriefing after critical incidents for anaesthetic trainees.
Citation Text:
Tan H. Debriefing after critical incidents for anaesthetic trainees. Anaesth Intensive Care. 2005;33(6):768-72.
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psnet.ahrq.gov/issue/misinformation-medical-literature-what-role-do-error-and-fraud-play
November 02, 2011 - Commentary
Misinformation in the medical literature: what role do error and fraud play?
Citation Text:
Steen G. Misinformation in the medical literature: what role do error and fraud play? J Med Ethics. 2011;37(8):498-503. doi:10.1136/jme.2010.041830.
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psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-process
February 13, 2013 - Newspaper/Magazine Article
Near-miss event analysis enhances the barcode medication administration process.
Citation Text:
Near-miss event analysis enhances the barcode medication administration process. Magee MC; Miller K; Patzek D; Madera C; Michalek C; Shetterly M.
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - potential for medical errors.(12)
In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented
with the use of a standardized checklist requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - Although ED physicians felt he had simple bruising from the fall, they noted that he was in severe pain requiring … proportion to the skin manifestations is a consistent feature of NF
In this case, the patient's severe pain requiring
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - This is because the Universal Protocol does not differentiate between types of cases requiring
imaging … For example, a change in hospital policy
requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - The Case
A 74-year-old man had a long history of coronary artery disease requiring coronary artery bypass … occupancy and prioritize elective admissions.(4) Subsequently, during daily surges of ED patients
requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - While waiting for the diagnostic tests, the patient had progressively severe pain, requiring relatively … challenging
There are often weight restrictions for diagnostic tests (e.g., CT scanning)
Abdominal processes requiring
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - The patient
had a stormy postoperative course, complicated by aspiration pneumonia requiring intubation … more than 1500 such patients, only a tiny minority (0.2%) went on to develop clinical
appendicitis requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - transcription step that led to the wrong sodium concentration being entered into the computer
Without CPOE, requiring … checked the PN label against original order
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*
Take-Home Points
PN is a high-alert medication requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring
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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/two-wrongs-dont-make-right-kidney
April 01, 2010 - This is because the Universal Protocol does not differentiate between types of cases requiring imaging … For example, a change in hospital policy requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - For patients requiring intermittent paracentesis for symptom relief, it would also be important to ensure … they are taking diuretic therapy or not requiring an increase in that therapy.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - are also known as critical values, or more accurately as "alert" values,
since some reflect errors requiring … immediate correction rather than clinical conditions requiring immediate
treatment.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - However, he rapidly
experienced further respiratory decompensation requiring intubation and mechanical … ventilation, as well as
hemodynamic compromise requiring vasopressor support.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel
perforation requiring … antibiotics are warranted, rather than relying on evidence-based
criteria), and health care system factors (requiring
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - an interruption.(13) Consequently, inadequate laboratory test result follow-up is a system problem
requiring … Inadequate laboratory test result follow-up is a system problem requiring a system solution.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - potential for medical errors.( 12 ) In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented with the use of a standardized checklist requiring
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - beta-glucuronidase in the newborn intestine and, now lipid soluble again, is reabsorbed into the portal circulation, requiring … isoimmunization, maternal antibody can persist for months, and can continue to cause hemolysis, sometimes requiring