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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - In fact, these errors and their serious consequences prompted requirements in hospitals for medication
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - rigorous research that captured key elements of context, clinical outcomes, and potential unanticipated consequences
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - " can be short-lived if the interdependencies among information needs, communication processes, and consequences
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psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - should be able to:
• Recognize common and serious pitfalls in diagnosis of Strongyloides and
potential consequences
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - transportation, a prohibition from driving may not have adverse social, cultural, or psychological consequences
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - problems of profiling and stigma, these “eyeball tests” proved highly inaccurate, sometimes with serious consequences
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - In adults, failure to diagnosis such injuries early carries dire clinical consequences with significant
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Although drug shortages can have direct consequences—such as when a critical medication is unavailable
-
psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - The patient’s INR was subtherapeutic for 3 days, but no untoward clinical
consequences occurred.
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - June 16, 2019
WebM&M Cases
Unintended Consequences of
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Ischemia
August 31, 2022
WebM&M Cases
The Consequences
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psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
October 27, 2021 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Fortunately, this patient did not suffer any long-term consequences.
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - December 21, 2022
Evaluation of medium-term consequences of implementing commercial computerized
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Some unintended consequences of information technology in health care: the nature of patient care information
-
psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - reminders) may help prevent errors but should be studied for acceptability,
utility, and unexpected consequences
-
psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - October 7, 2011
Medical misdiagnoses can have fatal consequences.
-
psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - Some unintended consequences of information technology in health care: the nature of patient care information
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - most severe SSTI and the diagnosis is often missed or delayed
Delay in diagnosis can have devastating consequences