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- Communication Improvement 1
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Teamwork 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Medication Safety
- Overtreatment 1
- Psychological and Social Complications 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
Journal Article > Commentary
Sacarny A, Barnett ML, Agrawal S. NEJM Catalyst. April 10, 2019.