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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - This situation can lead to important abnormalities going untreated if clear lines of team communication
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - One thing we've learned is that how to do it best does vary a lot by the specific
clinical situation
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - learn about trying to
improve quality and safety that you didn't know until you found yourself in that situation
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - game in health
care, we would say to people "Do not put yourself at risk when you're dealing with the situation
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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - problems, and knows that in the last 1000 cases an alarm has
fired in this type of patient—in this situation
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psnet.ahrq.gov/print/pdf/node/854855
January 01, 2024 - Situation Monitoring
Engaging the patient as observer to promote hand hygiene compliance in ambulatory
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - they could know that the assessment had been done hours earlier and was now irrelevant to the current situation
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - fortunate to have landed in the company of some very smart, generative people who helped rescue me from my situation
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - However, now given our situation with COVID you don’t want to be too close to that patient and we have … The current situation is evolving so quickly and forcing us to use telemedicine, we find we need to consider
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - If you take the old situation and look at it, I think you'll realize that it's a little bit odd.
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Downl…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/49502/psn-pdf
February 01, 2006 - Deciphering the Code
February 1, 2006
Goldstein MK. Deciphering the Code. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/deciphering-code
The Case
An 85-year-old man with advanced oxygen-dependent chronic obstructive pulmonary disease (COPD)
presented to the emergency department (ED) with increasing shortn…
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Hazards of Loading Doses
Citation Text:
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. 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/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - The Magnetic Deflection
Citation Text:
Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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