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psnet.ahrq.gov/issue/qualitative-study-examining-influences-situation-awareness-and-identification-mitigation-and
July 16, 2014 - This study used focus groups with nurses, respiratory therapists, and resident physicians to explore
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psnet.ahrq.gov/issue/hamilton-acute-pain-service-safety-study-using-root-cause-analysis-reduce-incidence-adverse
January 12, 2011 - The rates of overall events, respiratory depression, severe hypotension, and pump programming errors
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psnet.ahrq.gov/issue/objective-medical-emergency-team-activation-criteria-case-control-study
June 22, 2009 - The authors found that respiratory rate, heart rate, systolic blood pressure, and level of consciousness
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psnet.ahrq.gov/issue/four-years-experience-hospitalist-led-medical-emergency-team-interrupted-time-series
October 03, 2011 - A rapid response system consisting of a hospitalist, critical care nurse, and respiratory therapist
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Commentary
A 17-month-old female infant in the pediatric intensive care unit (PICU) developed acute respiratory … She was immediately
intubated without difficulty and her respiratory status was stabilized. … Acknowledgements: We would like to thank Jens Jensen, Joseph Cravero, and Dartmouth’s Pediatric
ICU nursing and respiratory … Putative Role in this Case
Risk Priority
(see figure)
Patient Factors
Patient condition Acute respiratory … doctor fails to inform the anesthesiologist doing an emergency nasal
intubation that the patient in respiratory
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - A chest x-ray showed diffuse pulmonary infiltrates consistent with acute respiratory distress syndrome … The patient was intubated for type I (hypoxemic) respiratory failure, and placed on high flow oxygen. … Shortly thereafter, the respiratory therapist arrived and noticed that the patient was being treated
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - the patient's worsening level of consciousness was attributed to "senile dementia" and not impending respiratory … Over the course of the day, the patient developed worsening respiratory distress and became comatose, … She subsequently developed respiratory failure requiring intubation and renal failure requiring dialysis … Thus, delirium was likely the presenting symptom of impending hypercarbic respiratory failure.
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - definitions ("Sepsis-1") defined sepsis as infection leading to abnormalities in temperature, heart rate, respiratory … Sequential Organ Failure Assessment (qSOFA) score points (1 point each for altered mental status, elevated respiratory … pathophysiology of sepsis is the presence of organ dysfunction, such as hypotension, elevated lactate, respiratory … a Stroke
June 1, 2018
WebM&M Cases
Acute Respiratory
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - showed
systolic blood pressure around 90 mm Hg, mean arterial pressure (MAP) 60-70, pulse 110-120/min,
respiratory … patient’s vital signs showed
a blood pressure of 88/40, mean arterial pressure of 57, pulse 142/min, respiratory … an example, the MEWT system would have been triggered, based on 2 maternal
triggers (pulse >110 and respiratory … (By
comparison, MERC might not have triggered, because of its higher pulse threshold of 120 and respiratory
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psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk
May 19, 2021 - November 11, 2020
Process failures that increase the risk of infection through respiratory
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psnet.ahrq.gov/issue/surgeons-opioid-prescribing-habits-are-hard-kick
August 28, 2019 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory
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psnet.ahrq.gov/node/836811/psn-pdf
April 07, 2022 - huddles are led by the
house supervisor and including nursing representatives, on-call hospitalist, respiratory
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psnet.ahrq.gov/issue/technology-education-and-safety-3
October 11, 2023 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - In the emergency department, she was ill appearing and in some respiratory distress. … notable for a temperature of 38.6° C, heart rate of 115 beats per minute, blood pressure of 104/68 mm Hg, respiratory … The patient developed respiratory failure requiring mechanical ventilation as well as septic shock requiring
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psnet.ahrq.gov/issue/accidents-claiming-and-regional-subcultures-are-medical-errors-and-malpractice-lawsuits
October 16, 2024 - Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory
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psnet.ahrq.gov/issue/research-webairs-incident-reporting-system
February 15, 2023 - Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory
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psnet.ahrq.gov/issue/addressing-opioid-epidemic-there-role-physician-education
February 22, 2023 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory
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psnet.ahrq.gov/issue/medication-safety-look-alikesound-alike-drugs-home-care
February 03, 2021 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory
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psnet.ahrq.gov/issue/2022-john-m-eisenberg-patient-safety-and-quality-awards
August 02, 2023 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory
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psnet.ahrq.gov/issue/2021-john-m-eisenberg-patient-safety-and-quality-awards
August 02, 2023 - May 11, 2022
Clinician distress and inappropriate antibiotic prescribing for acute respiratory