-
psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - WebM&M Cases
Getting a Good Report Card: Unintended Consequences
-
psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - Counterpoint Zero Harm Goals May Have Unintended Negative Safety Consequences The rationale for setting … allocation, commentators have also questioned how zero avoidable harm can be reliably measured, and the consequences … Those factors could help them avoid some of the negative unintended consequences of zero harm goals that
-
psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive
Partners in the Transformation of Health Care
January 1, 2015
Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health
Care. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
-
psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - May 1, 2019
WebM&M Cases
Consequences of Medical Overuse
-
psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Opioid Epidemic
Interventions designed to prevent overprescribing of opioids may result in unintended consequences
-
psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - September 1, 2006
Perspective
The Unintended Consequences
-
psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - In other domains where prediction is applied—like which movie or product you may enjoy—the consequences
-
psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - There are also
some economic drivers to shift the financial risk and exposure of financial consequences
-
psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - increase in handoffs that comes with duty hour restrictions, has been one of the most striking unintended consequences … Cases
Fumbled Handoff
March 1, 2004
Potential unintended consequences
-
psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - All these circumstances may lead to serious consequences without strong communication strategies to ensure … packing removed but I feel like there is something still inside me. "
The second case illustrates the consequences
-
psnet.ahrq.gov/perspective/weekend-effect
April 01, 2008 - April 12, 2023
Potential unintended consequences due to Medicare's "No Pay for Errors
-
psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - If the
incorrect dose was dispensed and administered but the patient experienced no clinical consequences
-
psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - The Commentary This case illustrates how well-intentioned care can sometimes have catastrophic consequences
-
psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - medication, metformin, which is pregnancy category B and is not known to be associated with specific adverse consequences
-
psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
September 20, 2011 - September 1, 2004
WebM&M Cases
Unintended Consequences
-
psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Luckily, she did not suffer any obvious or immediate consequences, but the administration of tPA to a
-
psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - for perinatal
mental health are important because untreated mental health problems can have serious consequences
-
psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - Some unintended consequences of information technology in health care: the nature of patient care information
-
psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - one in which remaining colleagues can feel free to report their own mistakes without fear of undue consequences
-
psnet.ahrq.gov/web-mm/back-basics
July 13, 2010 - If not recognized or anticipated, DKA carries the potential for lethal consequences.( 1,2 ) A key error