{1}
##LOC[OK]##
{1}
##LOC[OK]##
##LOC[Cancel]##
{1}
##LOC[OK]##
##LOC[Cancel]##
Skip Navigation
www.ahrq.gov
search
home
whatsnew
collection
primers
glossary
newsletter
mypsnet
newsletter
The Collection
>
Hard to Swallow.
Driver J. AHRQ WebM&M [serial online]. October 2004.
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.
Free full text
Related Resources
COMMENTARY
Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
COMMENTARY
Recurrent Hypoglycemia: A Care Transition Failure?
Eytan T. AHRQ WebM&M [serial online]. October 2008.
COMMENTARY
Discharge Fumbles.
Forster A. AHRQ WebM&M [serial online]. December 2004.
NEWSPAPER/MAGAZINE ARTICLE
Multiple latent failures align to allow a serious drug interaction to harm a patient.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
View all related resources...
Download:
Adobe Reader
Email
Find Related Resources by...
Resource Type
Commentary
Target Audience
Health Care Providers
Health Care Executives and Administrators
Risk Managers
Information Professionals
Clinical Area
Allied Health Services
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Medical Complications
Error Types
Latent Errors
Approach to Improving Safety
Root Cause Analysis
Communication between Providers
Electronic Health Records
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)