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the online journal and forum on patient safety and health care quality. This site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety
("Spotlight Cases")
, and forums for online discussion. CME credit is available.
Register here
. Registration allows you to submit cases, participate in the Forums, and receive notice of new issues and updates to the site.
Breakdown of AHRQ WebM&M; Users by Provider and Non-Provider Roles
Source
Thin Air
A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why—the patient is mistakenly receiving compressed room air.
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Commentary By:
David M. Gaba, MD
Moved Too Soon
A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues.
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Commentary By:
Peter Lindenauer, MD, MSc
Lap Burn
While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.
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Commentary By:
Kay Ball, RN, MSA
Electronic Err
After an admitting physician bases the dosages of medication on an outdated electronic medication list, the patient's heart nearly stops.
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Commentary By:
Paul C. Tang, MD
Hard to Swallow
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.
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Commentary By:
Jeffrey Driver, JD, MBA
Writers of cases
selected
for posting receive an honorarium.
Produced for the
Agency for Healthcare Research and Quality
, by a
team of editors
at the
University of California, San Francisco
with guidance from a prominent
Editorial Board
and
Advisory Panel
. The AHRQ WebM&M site was designed and implemented by DoctorQuality.
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