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psnet.ahrq.gov/periodic-issue/periodic-issue-437
April 10, 2024 - Fitzpatrick, MD | April 24, 2024
This pair of cases highlight the immediate and long-term consequences
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Although it
was unclear whether the delayed notification had adverse clinical consequences (the role
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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/40-k
January 12, 2011 - The patient’s INR was subtherapeutic for 3 days, but no untoward clinical consequences occurred.
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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/web-mm/double-dosing-rules
February 03, 2010 - Sometimes their consequences are hidden, becoming apparent only when they occur in sequence with each
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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
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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
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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/critical-order-set-change-and-critical-limb-ischemia
July 02, 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/superficial-report-leads-deep-problem
July 01, 2012 - period of change will be marked in years, and the transition may bring about confusion and unexpected 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/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/node/50756/psn-pdf
December 18, 2019 - recommendations on the use of opioids for the treatment of chronic pain, resulting in some unintended
consequences
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - Fortunately, the patient did not experience any adverse consequences from the hypernatremia.
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - The patient had a minor nosebleed but no other adverse consequences.
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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - Fortunately, the patient did not experience any adverse consequences as a result of the error.
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - June 30, 2011
National study on the frequency, types, causes, and consequences of voluntarily
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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/node/33884/psn-pdf
July 01, 2019 - Some unintended consequences of
clinical decision support systems.