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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
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Types of unintended consequences related to computerized provider order entry.
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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
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - epidural and 1 in 220,000 for spinal
anesthetics.(7) Even though the complication is unusual, the consequences—often
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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
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - by the relatively infrequent occurrence of TB as a cause of respiratory failure, along with the dire consequences
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - or surrogate) ideally should be
able to understand the choices being considered, assess the likely consequences
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - transportation, a prohibition from driving may not have adverse social, cultural,
or psychological consequences
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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - appropriate backdrop to discuss defensive medicine more
broadly and outline the associated costs and consequences
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - of order sets all
require careful attention to the potential of harm to patients and of unintended consequences
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - training and videos that explicitly illustrate the hazards and highlight the potential catastrophic consequences
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Therefore, losing access to IT systems and to the data contained
in these systems has dire consequences
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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
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Fortunately for this patient, this mistake did not cause her adverse long-term clinical consequences.
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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
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - Clinicians also need to be aware of high-alert medications, which can have catastrophic consequences
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psnet.ahrq.gov/perspective/weekend-effect
April 01, 2008 - April 12, 2023
Potential unintended consequences due to Medicare's "No Pay for Errors
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psnet.ahrq.gov/node/33581/psn-pdf
September 07, 2019 - If the
incorrect dose was dispensed and administered but the patient experienced no clinical consequences
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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - environments by those who are unfamiliar with this imaging modality—at times with serious, and even fatal, consequences
-
psnet.ahrq.gov/node/33600/psn-pdf
September 08, 2019 - In this model,
errors made by individuals result in disastrous consequences due to flawed systems—the