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psnet.ahrq.gov/continuing-education
February 26, 2025 - The commentary describes the appropriate evaluation for acute abdominal pain, the importance of imaging … discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate … The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Patient A was discharged after he received appropriate clinical care and his acute symptoms resolved, … The BCMA process requires appropriate bar code labeling and functional scanning technology. 11 Only
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - these factors, published clinical algorithms are often imperfect in making the diagnosis and guiding appropriate … Take-Home Points
Because of variable symptoms and microbiologic factors, the diagnosis and appropriate … Two swabs were taken from the same child within 20 seconds and immediately plated onto appropriate agar
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psnet.ahrq.gov/web-mm/collegiality-vs-competence
August 28, 2024 - Efforts to avoid appropriate privilege restrictions put patients at risk and do a disservice to the physicians
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - They should have greater opportunities to participate in deciding appropriate workloads and professional … required to document their interventions to prevent adverse drug events, and should be reimbursed for appropriate … August 14, 2024
Improving appropriate use of peripherally inserted central catheters
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - intervention; permanent loss of muscle tissue and functional impairment could have been prevented with appropriate … compartment. 6 Severe pain out of proportion to the patient’s injury and pain that does not improve with appropriate … predictive value in many clinical settings. 8 The American Academy of Orthopaedic Surgeons’ (AAOS) “Appropriate … Did they escalate their concerns about CS to an appropriate supervisor (e.g., attending physician)? … November 25, 2020
WebM&M Cases
Delay in Appropriate
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Review and (where appropriate) discontinuation of "culprit" medications associated with increased risk … Early access to advice, mobility aids, and (where appropriate) exercise from physiotherapists.
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - Adherence to these clinical standards (for example, administration of appropriate antimicrobial prophylaxis … risk (for example, ensuring that preoperative antimicrobial prophylaxis has been administered at the appropriate
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - In this situation, using the CDC's electronic algorithm to determine appropriate action at relevant … free, easily accessible electronic resource provides an efficient means for providers to determine appropriate
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - periprocedural period involves a comprehensive and coordinated effort to ensure that patients receive the most appropriate … Postoperative Medication Management: Ensure that appropriate medications are resumed or continued postoperatively … Utilize information systems to “push” reminders (or cautions) to patients regarding appropriate times
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psnet.ahrq.gov/issue/computerized-clinical-decision-support-during-medication-ordering-long-term-care-residents
February 11, 2009 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate
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psnet.ahrq.gov/web-mm/language-barrier
February 28, 2024 - provide adequate language assistance to LEP patients.( 8 ) This case underscores the importance of having appropriate … The disaster that occurred in this case also could have been averted had the pharmacy provided appropriate … perform a practice or actual dosing of the medication (with liquid medication syringes marked at the appropriate
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - rates of distress.( 7 ) Additional qualitative data suggest that error disclosure (and apology when appropriate … perceived risk of full error disclosure (as described in this case) ( 19 ), such disclosure is clearly the appropriate … Interestingly, while it is not appropriate to burden patients and their families with care providers'
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Interval imaging at this point would have been appropriate and would likely have demonstrated progression … Initial percutaneous drain placement for source control is appropriate in some cases, including in the … discharge needs, such as establishing a primary care provider and setting up outpatient appointments in an appropriate
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psnet.ahrq.gov/issue/avoiding-errors-associated-insulin-therapy
April 06, 2022 - December 30, 2014
Safe and appropriate use of insulin and other antihyperglycemic agents
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psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
November 13, 2019 - February 21, 2018
Ensuring critical instruments and devices are appropriate for reuse
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - This bundle of practices resulted in significant increases in appropriate prescribing and monitoring
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Consequences
Functional Suitability
The degree to which software features are complete, accurate, and appropriate … Development of potentially unsafe workarounds
Lack of data coding,
standardization, and
structure
Lack of appropriate
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - near-miss high-risk patient safety event in transfusion services must include: Notification of the appropriate … documented corrective and preventative action plan (CAPA) submitted to laboratory leadership: Notify appropriate … The appropriate response to a near-miss high-risk transfusion event includes: (1) report the event to
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - during insertion. 3,4 These tubes may contain a guidewire or may have a weight at the tip to facilitate appropriate … recommend radiographic examination by chest or abdominal X-ray as the “gold standard” for confirmation of appropriate … which led to pneumothorax. 12
NGTs should be routinely assessed every 2 to 4 hours for appropriate … validated delirium screening tool, mindful prescription and administration of deliriogenic medications, appropriate