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The Dangerous Detour.
Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.
En route to x-ray, a suicidal patient attempts to hang herself in washroom.
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Facility and Group Administrators
Clinical Area
Mental Health Care (Psychiatry & Clinical Psychology)
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Error Types
Active Errors
Latent Errors
Near Miss
Approach to Improving Safety
Practice Guidelines
Reminders
Communication between Providers
Provider-Patient Communication
Human Factors Engineering
Education and Training
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)