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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Indicator [PSI] 90) using weights that reflect both the frequency of component PSIs and their downstream consequences
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psnet.ahrq.gov/toolkits
March 01, 2025 - Methicillin-resistant Staphylococcus aureus (MRSA) infections can lead to serious consequences among
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - ordered opioids, including strategies for using these medications effectively and their unintended consequences
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - Fortunately, the patient did not experience any adverse consequences from the use of the lidocaine for
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - tests were negative for HIV and hepatitis, meaning that the
patient did not experience any long-term consequences
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - that broad-spectrum antibiotic coverage is in the patient’s best interest,
despite possible societal consequences
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - View More
Related Resources
WebM&M Cases
The Consequences
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - What are the
consequences of
error?
Typically, no impact.
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - The consequences in either case—local tissue injury with the use of peripheral vasopressors, or prolonged
-
psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - Any delay of
appropriate treatment may lead to irreversible consequences.
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - The patient did not experience any neurologic consequences from the cardiac arrest and was able to be
-
psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - (or surrogate) ideally should be able to understand the choices being considered, assess the likely consequences
-
psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - anesthesia was reversed, and the patient was returned to her room and fortunately did not have
any consequences
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - extubation and eventual reintubation.( 5 ) Laryngeal edema and postextubation stridor are potential consequences
-
psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - recognized at the time of surgery, it can always be repaired, usually laparoscopically with minimum consequences
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - thrombotic complications.( 1 ) In the past, such complications were often considered to be inevitable consequences
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - In ex post evaluation, it is particularly important to detect and assess unforeseen consequences. … Second, they need to improve their use of monitoring and evaluation of both intended and unintended consequences
-
psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - For example, a patient may
demonstrate appreciation by verbalizing the consequences to themselves by … Cognitive underspecification: Its variety and consequences.?In B.
J. Baars (Ed.),?
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - decisions, developers need to proactively develop comprehensive mitigation strategies to address unintended consequences … invest in research and evaluation that will enable this purposeful learning risks repeating the tragic consequences