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Thin Air.
Gaba DM. AHRQ WebM&M [serial online]. October 2004.
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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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Physicians
Nurses
Engineers
Clinical Area
Critical Care
Pulmonology
Critical Care Nursing
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Approach to Improving Safety
Forcing Functions
Medical Device Design
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)