-
psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - The DTI should be
continued until the platelet count has recovered and the patient is adequately anticoagulated … HIT
and thrombosis, as in this case, anticoagulation, usually with a coumarin derivative, should be continued … Although HIT had been documented and treated during that hospitalization, the patient continued to receive
-
psnet.ahrq.gov/training-education
October 01, 2025 - Training and Education Overview
PSNet offers an unparalleled set of resources for patient safety training and education. In this section, you will have the opportunity to read WebM&M (Morbidity & Mortality) Spotlight Cases and complete the interactive learning modules for continuing medical education (CME), maintenan…
-
psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
-
psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - In the emergency department (ED) of Hospital Y, the patient's AICD continued to fire shocks. … Unfortunately, the patient continued to have more ventricular arrhythmias and firings of his AICD even
-
psnet.ahrq.gov/issue/fentanyl-patch-can-be-deadly-children
January 13, 2021 - Fact Sheet/FAQs
Accidental exposures to fentanyl patches continue to be deadly to children.
Citation Text:
Accidental exposures to fentanyl patches continue to be deadly to children. Rockville, MD: US Food and Drug Administration; 2021.
Copy Citation
Save
Save …
-
psnet.ahrq.gov/issue/industry-automates-adverse-events-continue-haunt-caregivers
February 08, 2023 - Newspaper/Magazine Article
As industry automates, adverse events continue to haunt caregivers.
Citation Text:
Wetzel TG. As industry automates, adverse events haunt caregivers. Health data management. 2011;19(2):86, 88, 90 passim.
Copy Citation
Format:
Google Scholar PubM…
-
psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - He continued the anti-retroviral HIV medications for which he had refills. … sensitivity but high specificity as a diagnostic test).( 5 ) Of interest, he indicates that he has continued
-
psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Despite the treatment, the
TSB level continued to climb, reaching 18 mg/dL (308 ?mol/L). … appropriate phototherapy has decreased the need for such risk-laden exchange transfusions, although
continued
-
psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - This was helpful in
keeping sites on track with continued implementation. … leadership in the program at the learning session and encouraged
them to remain involved to promote continued
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.458_slideshow.ppt
October 01, 2018 - The patient's blood pressure continued to trend downward to 60/40 mm Hg. … was transferred to the CCU in critical condition.
6
Case: Challenges in Sepsis Diagnosis (4)
He continued
-
psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - The physician did not see the form, and the patient continued to
receive thickened liquids. … order to the time the diagnostic test results or consult is
reviewed and an order for NPO status is continued
-
psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - treatment with
intravenous (IV) amphotericin (an antifungal drug), and broad-spectrum antibiotics were continued … The patient who had received the
drug continued to require hemodialysis for several more days.
-
psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - elders, accounting for an estimated $7.2 billion in health expenditures in 2001.( 3 ) As a result of continued … First, the continued use of PIM in older adults remains a problem and dramatically increases the likelihood
-
psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Given the continued challenge in demonstrating best practices associated with improving care transitions … to the Centers for Medicare & Medicaid Services asked for immediate action, which should stimulate continued
-
psnet.ahrq.gov/node/60610/psn-pdf
June 24, 2020 - Over the next 3 years, her dysmenorrhea continued, and she developed severe abdominal cramps,
bloating … She was continued on oral contraceptives by her gynecologist. … endometriosis-common-and-commonly-missed-and-delayed-diagnosis
Once the diagnosis was made by the general surgeon, the patient continued
-
psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - follow-up visits, her physician extended the hydrocodone/acetaminophen for an additional
month and continued … Over the next several weeks, her
pain continued to worsen. … anti-inflammatories and conservative home measures (including exercise,
topical cold or heat, and continued
-
psnet.ahrq.gov/issue/elusive-balance-residents-work-hours-and-continuity-care
July 19, 2017 - Commentary
An elusive balance — residents' work hours and the continuity of care.
Citation Text:
Okie S. An elusive balance--residents' work hours and the continuity of care. N Engl J Med. 2007;356(26):2665-2667.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote …
-
psnet.ahrq.gov/issue/bridging-gaps-handoffs-continuity-care-based-approach
January 07, 2015 - Study
Bridging gaps in handoffs: a continuity of care based approach.
Citation Text:
Abraham J, Kannampallil TG, Patel VL. Bridging gaps in handoffs: a continuity of care based approach. J Biomed Inform. 2012;45(2):240-54. doi:10.1016/j.jbi.2011.10.011.
Copy Citation
Format:
…
-
psnet.ahrq.gov/node/867340/psn-pdf
December 11, 2024 - Multiple points of system failure underpin continuous
subcutaneous infusion safety incidents in palliative care:
a mixed methods analysis.
December 11, 2024
Brown AJ, Yardley S, Bowers B, et al. Multiple points of system failure underpin continuous subcutaneous
infusion safety incidents in palliative care: a mixed…
-
psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - with tranexamic acid and oral contraceptives
• Presented the following day to a different ED with
continued