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psnet.ahrq.gov/issue/patient-safety-case-based-innovative-playbook-safer-care-second-edition
September 11, 2019 - January 10, 2025
WebM&M Cases
Discharged with IV antibiotics
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
June 02, 2025 - No Antibiotics
Yes No ? MEDICATION ALLERGIES:
Yes No ?
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - The patient was given was given an isotonic fluid bolus of 30 ml/kg and started on broad-spectrum antibiotics … in the radial artery for hemodynamic monitoring, but this line was inadvertently used to infuse an antibiotic … Sodium thiopental, diazepam, diclofenac and antibiotics frequently induce limb-threatening ischemia when … pedis arterial catheters are unlikely to cause thrombosis and necrosis in adults unless drugs such as antibiotics
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - Based on this and the increasing incidence of MRSA in all SSTIs, some have recommended empiric antibiotics … Unfortunately, such signs are present in only 43% of these patients.( 29 ) Broad-spectrum antibiotics … progression of infection with migration of the margins of erythema and skin induration despite the use of antibiotics … National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/deliberative-methods-demonstration-executive-131125.pdf
November 01, 2013 - These were:
• Comparing Hospital Quality
• Upper Respiratory Infection (URI) in Children: Antibiotics … could prevent the development of
antibiotic-resistant superbugs such as methicillin-resistant Staphylococcus … Similarly, participants who had been
unaware of the risks to society from the overuse of antibiotics … tended to become more
willing to accept limits on care that promote good antibiotic stewardship. … related to health care costs.
11
• Attitudes regarding use of medical evidence to restrict antibiotic
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0075_03-10-2009.pdf
January 01, 2009 - including
Hispanics)
Intervention(s): Aminosalicylates, corticosteroids, immune system suppressors,
antibiotics
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psnet.ahrq.gov/issue/soaring-numbers-111-callers-forced-wait-call-back
September 21, 2016 - August 24, 2016
Why do hospital prescribers continue antibiotics when it is safe to stop
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digital.ahrq.gov/2020-year-review/research-dissemination/reaching-research-community-through-web-conferences
January 01, 2020 - network allows children to be seen quicker than an in-person visit as well as receive medication and antibiotics
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - He was treated with ceftriaxone and doxycycline (antibiotics) for his pneumonia. … team was also correct to check the patient's INR at discharge, since they had treated the patient with antibiotics … the primary care doctor specifically for INR testing in the setting of recent acute illness and new antibiotic
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship4.html
August 01, 2024 - risk of wrong (false positive) diagnosis of urinary tract infections and lead to inappropriate use of antibiotics
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psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - critically ill for many days and had Staphylococcus aureus in her bloodstream for more than a week despite antibiotic … In addition to a prolonged hospitalization, he required 6 weeks of intravenous antibiotics as a result … This includes appropriate antibiotic coverage and aggressive management for any early signs of sepsis … March 1, 2007
WebM&M Cases
Inappropriate Antibiotic
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - The emergency department (ED) physician ordered Rocephin (the brand name for the antibiotic
ceftriaxone … medicine administration area, the nurse found a partially empty vial of parenteral cefazolin, a different
antibiotic … First, the child received an overdose of antibiotics.
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - DC: When a patient on antibiotics develops symptoms that might be indicative of Clostridium difficile … colitis,
it can often be preceded by what we call antibiotic-associated diarrhea. … However, if you identify them early when they develop diarrhea
on antibiotics (from information in the … EMR), it may signal that they are at increased risk for C. difficile and
that their antibiotics should
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - Resources From the Same Author(s)
Effect of behavioral interventions on inappropriate antibiotic … July 1, 2016
Time of day and the decision to prescribe antibiotics.
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www.ahrq.gov/ncepcr/reports/2025-annual-report/digital-healthcare.html
August 01, 2025 - Implementing Telemedicine to Improve Appropriate Antibiotic Prescribing for Acute Respiratory Tract Infections … the management of acute respiratory tract infections, including reducing inappropriate prescribing of antibiotics
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/ocr-protocol-final_1.pdf
December 18, 2019 - hemorrhage by mode
(vaginal, cesarean)c
• Uterine infection (i.e.,
choriamnionitis,
administration of
antibiotics … time
between hospital
admission to birth that
is insufficient to enable
complete GBS
prophylaxis antibiotics … time
between hospital
admission to birth that
is insufficient to enable
complete GBS
prophylaxis antibiotics … time
between hospital
admission to birth that
is insufficient to enable
complete GBS
prophylaxis antibiotics … time
between hospital
admission to birth that
is insufficient to enable
complete GBS
prophylaxis antibiotics
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-guidance-tests-outcomes_methods.pdf
July 01, 2012 - prophylactic antibiotics or quarantine after exposure to an infectious individual, or diversion of
resources … They included
a review of the clinical management effects that would result from antibiotic treatment … might also have explicitly
included an outcome that examines whether the screening leads to receipt of antibiotic … been appropriate to consider outcomes that are associated with screening
but are not the result of antibiotic … have also considered other relevant parties; these might include
the mother’s partner and society, as antibiotic
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/012-blood-culture-practices-webinar.docx
October 01, 2024 - Slide 3
Fundamental Best Practices
SAY:
In addition to the four main strategies, Antibiotic Stewardship … Blood culture stewardship is designed to optimize bacteremia detection and to reduce inappropriate antibiotic … False positives caused by contamination result in further adverse consequences, including unnecessary antibiotic … · Is the primary site of infection not readily available for culture prior to antibiotic initiation? … mistakes in blood culture collection, was misdiagnosed twice and given multiple courses of broad-spectrum antibiotics
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - However, drainage persisted, prompting further observation and a course of oral antibiotics. … He was diagnosed with sepsis, which did not respond to escalating antibiotic treatment. … The role of antibiotic therapy for CSF fistulas and pseudomeningoceles is not clear. … However, an analysis of published reports suggested that antibiotics do not decrease the short- or long-term … Antibiotic prophylaxis in unrepaired CSF fistulae.
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - laboratory results and chart revealed that the ICU team had ordered blood cultures and broad-spectrum antibiotics … while the patient was in the ED, but the antibiotics were not administered until after the patient was … Antibiotic orders were placed, but the ED nurse did not see the order because she was busy assisting