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psnet.ahrq.gov/issue/important-change-heparin-container-labels-clearly-state-total-drug-strength
December 16, 2020 - Government Resource
Important change to heparin container labels to clearly state the total drug strength.
Citation Text:
Important change to heparin container labels to clearly state the total drug strength. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; Dece…
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psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
November 28, 2018 - Book/Report
Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health.
Citation Text:
Medical Device Safety Action Plan: Protecting Patients, Promoting Public Health. Silver Spring, MD: US Food and Drug Administration; April 2018.
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psnet.ahrq.gov/issue/use-common-gas-outlet-supplementary-oxygen-during-caesarean-section
August 04, 2021 - Commentary
Use of the common gas outlet for supplementary oxygen during Caesarean section.
Citation Text:
Edsell MEG, Erasmus PD. Use of the common gas outlet for supplementary oxygen during Caesarean section. Anaesthesia. 2005;60(11):1152-3.
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psnet.ahrq.gov/issue/preventing-adverse-events-cataract-surgery-recommendations-massachusetts-expert-panel
July 16, 2019 - Study
Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel.
Citation Text:
Nanji KC, Roberto SA, Morley MG, et al. Preventing Adverse Events in Cataract Surgery: Recommendations From a Massachusetts Expert Panel. Anesth Analg. 2018;126(5):1537-…
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Two days later, the patient suddenly arrested on the floor.
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psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - When the patient suddenly lost a pulse, providers initiated cardiopulmonary resuscitation, which led
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - die from hyperkalemia is a matter of speculation—because patients with severe hyperkalemia may
die suddenly
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - However, the child
made an unusual noise, which caused the anesthesiologist to turn around suddenly.
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Four
hours later, the patient suddenly became bradycardic to a heart rate of 20 beats per minute.
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - He gave the dose to the child who suddenly had difficulty breathing and collapsed.
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psnet.ahrq.gov/issue/hhs-seeks-input-medical-office-survey-patient-safety-culture-database-information-collection
March 13, 2024 - Press Release/Announcement
HHS seeks input on Medical Office Survey on Patient Safety Culture Database information collection.
Citation Text:
HHS seeks input on Medical Office Survey on Patient Safety Culture Database information collection. Agency for Healthcare Quality and Research. Fe…
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psnet.ahrq.gov/issue/analysis-deaths-related-anesthesia-period-1996-2004-closed-claims-registered-danish-patient
November 13, 2024 - Study
Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association.
Citation Text:
Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996-2004 from closed …
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psnet.ahrq.gov/issue/intraoperative-communications-between-pathologists-and-surgeons-do-we-understand-each-other
June 28, 2023 - Study
Intraoperative communications between pathologists and surgeons: do we understand each other?
Citation Text:
Wiggett A, Fischer G. Intraoperative communications between pathologists and surgeons: do we understand each other? Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arp…
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psnet.ahrq.gov/issue/surgical-crisis-management-skills-training-and-assessment-stimulation-based-approach
March 03, 2011 - Study
Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance.
Citation Text:
Moorthy K, Munz Y, Forrest D, et al. Surgical Crisis Management Skills Training and Assessment. Ann Surg. 2006;244(1). doi:10.1097/01.sl…
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psnet.ahrq.gov/issue/helsinki-declaration-patient-safety-anaesthesiology-past-present-and-future
January 14, 2014 - Commentary
The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.
Citation Text:
Mellin-Olsen J, Staender S. The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future. Curr Opin Anaesthesiol. 2014;27(6):630-634. doi:…
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psnet.ahrq.gov/issue/misdiagnosed-food-allergy-resulting-severe-malnutrition-infant
April 24, 2018 - Commentary
Misdiagnosed food allergy resulting in severe malnutrition in an infant.
Citation Text:
Alvares M, Kao L, Mittal V, et al. Misdiagnosed food allergy resulting in severe malnutrition in an infant. Pediatrics. 2013;132(1):e229-32. doi:10.1542/peds.2012-2362.
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psnet.ahrq.gov/issue/potentially-fatal-errors-gdh-pqq-glucose-dehydrogenase-pyrroloquinoline-quinone-glucose
June 22, 2011 - Press Release/Announcement
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.
Citation Text:
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology. MedWat…
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psnet.ahrq.gov/issue/improving-patient-safety-through-simulation-training-anesthesiology-where-are-we
October 13, 2018 - Review
Improving patient safety through simulation training in anesthesiology: where are we?
Citation Text:
Green M, Tariq R, Green P. Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We? Anesthesiol Res Pract. 2016;2016:4237523. doi:10.1155/2016/4237523.…
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psnet.ahrq.gov/issue/using-delphi-method-identify-human-factors-contributing-nursing-errors
June 10, 2015 - Study
Using a Delphi method to identify human factors contributing to nursing errors.
Citation Text:
Roth C, Brewer M, Wieck L. Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors. Nurs Forum. 2017;52(3):173-179. doi:10.1111/nuf.12178.
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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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