-
psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - October 28, 2020
WebM&M Cases
Preventing Complications
-
psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - More About The Topic
Long-Term Care
Nurses
Nurse Care
Medication Safety
Medical Complications
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - the inpatient psychiatric unit used the case as an opportunity to broadly consider not only medical complications
-
psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - associated with multiple adverse events including
progressive loss of kidney function, major cardiac complications
-
psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - significant patient morbidity and even mortality.(
3,9,10) Patients can experience immediate postoperative complications
-
psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - While the
complications and ultimate outcome of this case are exceedingly rare, unfortunately, the problem
-
psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - Effects/Adverse Drug Reactions
Medication Errors/Preventable Adverse Drug Events
Transfusion Complications
-
psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - (which requires hospitalization and
placement of an indwelling catheter, with concomitant risk of complications
-
psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - Care and maintenance to reduce vascular access complications: guideline supplement.
-
psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - October 28, 2020
WebM&M Cases
Preventing Complications
-
psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - During the hospitalization, she developed additional complications of SLE including cerebritis, hemolytic
-
psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - Resources
WebM&M Cases
Delayed Diagnosis of Kidney Transplant Complications
-
psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - risk
of subsequent MI, heart failure, and death.13 Furthermore, women also have increased risk of
complications
-
psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - We have to have this level of surveillance and interventions when complications are occurring.
-
psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - librarian and said, "I'm interested in how you prevent medical errors, and I've found papers about complications
-
psnet.ahrq.gov/node/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
-
psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
-
psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
-
psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
-
psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…