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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
November 15, 2023 - endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - Two days later, the patient suddenly arrested on the floor.
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psnet.ahrq.gov/issue/sudden-death-lung-embolism-after-inadvertent-infusion-zinc-oxide-shake-lotion
January 12, 2022 - Commentary
A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion.
Citation Text:
Pragst F, Correns A, Priem F, et al. A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion. Forensic Sci Int. 2007;170(2-3):207-12.
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psnet.ahrq.gov/periodic-issue/periodic-issue-306
August 25, 2021 - endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly
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psnet.ahrq.gov/issue/fentora-fentanyl-buccal-tablet
October 28, 2020 - Government Resource
Fentora (fentanyl buccal tablet).
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September 26, 2007
This announcement provides specific instructions on safe prescribing of a cancer pain…
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psnet.ahrq.gov/issue/fda-preliminary-public-health-notification-update-information-about-ralstonia-spp-associated
April 17, 2019 - Government Resource
FDA preliminary public health notification: update of information about Ralstonia spp. associated with Vapotherm Respiratory Gas Administration device.
Citation Text:
Food and Drug Administration; FDA.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - units become ill or otherwise unable to work their assigned shifts, the patient-to-nurse ratio may suddenly
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
March 29, 2023 - His peak airway pressures were initially 23-25 cm H 2 O but suddenly increased to 48-52 about 30 minutes … Thirty minutes into the operation the airway pressures suddenly increased from 25 to 50 cm of H 2 O and
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psnet.ahrq.gov/issue/san-diego-center-patient-safety
October 31, 2023 - Multi-use Website
San Diego Center for Patient Safety.
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March 6, 2005
The San Diego Center for Patient Safety (SDCPS) consists of a multidisciplinar…
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psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
September 21, 2023 - Suddenly there appeared to be very strong evidence that going through a checklist before a surgical procedure … Suddenly all of the nurses, anesthesia assistants, respiratory therapists, everyone's in the room; everyone
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psnet.ahrq.gov/issue/governor-signs-executive-order-creating-new-division-patient-safety
October 25, 2023 - Press Release/Announcement
Governor signs Executive Order creating new Division of Patient Safety.
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July 26, 2006
This news release announces the go…
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psnet.ahrq.gov/periodic-issue/periodic-issue-303
August 25, 2021 - endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly
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psnet.ahrq.gov/issue/opioid-medication-discontinuation-and-risk-adverse-opioid-related-health-care-events
November 16, 2022 - Nearly half of patients who had opioids suddenly discontinued or with short tapering lengths experienced
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psnet.ahrq.gov/issue/delivering-safer-health-care-western-australia-second-wa-sentinel-event-report-2005-2006
December 14, 2022 - Government Resource
Delivering Safer Health Care in Western Australia: The WA Sentinel Event Report 2010-2011.
Citation Text:
Department of Health of Western Australia, Patient Safety Directorate. Perth: Department of Health WA; 2011.
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
April 24, 2024 - Suddenly, it was a conversation that could happen at the dinner table, at the bowling alley, or at the … So suddenly, having more data may be good, but we have to be careful about how we curate it and take
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psnet.ahrq.gov/issue/abbott-diabetes-care-blood-glucose-meters
December 12, 2023 - Government Resource
Abbott Diabetes Care blood glucose meters.
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November 9, 2005
This announcement alerts patients and practitioners to a problem wi…
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psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures
November 08, 2023 - Sentinel Event Alerts
Preventing adverse events caused by emergency electrical power system failures.
Citation Text:
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert. 2006;37(37):1-3.
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
September 30, 2020 - has occurred, such that an equipment problem that might have been easily remedied before an event can suddenly
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psnet.ahrq.gov/periodic-issue/periodic-issue-311
September 29, 2021 - endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly
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psnet.ahrq.gov/periodic-issue/periodic-issue-310
September 29, 2021 - endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly