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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. 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/sick-and-pregnant
August 25, 2021 - Sick and Pregnant
Citation Text:
El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - frequently, hopefully it would be done in a simulated environment, so that they
would know how to respond
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Later that day, the patient deteriorated and failed to respond to resuscitation.
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Five ways to respond to a medical mistake.
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - They were no longer comfortable proceeding with the endoscopy, because they lacked the ability to respond
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - talk about how commitment to resilience is intended to be a collective process, such as how
do we respond
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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - If organizations have that data, I think
they will respond appropriately.
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - They were never going to respond to Intermountain.
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - In this case, we would propose the following changes: Most institutions respond to such errors by
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - perfect in the care we provide to our patients, we can identify problems, innovate solutions, and respond
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - substances they have already purchased and use them in an environment where there are people able to
respond
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - back pain, particularly instruction regarding the need for further evaluation if the patient does not respond
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - providers is critical to safe patient care, but care teams are often distracted or under time pressure to respond
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - The pain is typically severe and does not respond to standard amounts of postoperative pain medications
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - be perfect in the care we provide to our patients, we can identify problems, innovate solutions, and respond
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - 23 ) This approach must usually be combined with more specific red flag triggers, such as failure to respond