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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - set in question was developed to support a relatively complex
clinical workflow: administration of therapeutic … anticoagulation treatment with unfractionated heparin. … In the case described, one such metric might have been time from initiation of heparin to the
first therapeutic … This case involved a substantial change to an existing order set for therapeutic heparin: The ordering … J Diabetes Sci Technol. 2008;2:349-356.
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - TFFRS – Diabetes prevention: Interventions engaging community health workers. … This helped them overcome personal health barriers, so they’d be ready to get treatment. … pain and they have a variety of interventions, mental health and acupuncture, a variety of integrative therapies … people’s lives, sending them out to do things they don’t need to do, and avoid unnecessary tests or treatments … to translate that complex medical jargon related to national guidelines around preventive care and treatments
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - After three days of her first cycle of therapy, she complained of diffuse abdominal pain that lasted … This antagonism of dopaminergic function represents the mechanism by which chlorpromazine exerts its therapeutic … It also did not require the ordering provider to specify the indication for therapy. … jama.1966.03110140066019
Incidence, Diagnosis, and Management of QT Prolongation Induced by Cancer Therapies … February 1, 2023
WebM&M Cases
Challenges of Diabetes
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - Scale (COWS) and pharmacologic treatments. … facilities (or in licensed opioid agonist therapy [OAT] programs). … to longer term maintenance therapy using buprenorphine or methadone. … unhealthy behavior (e.g., alcohol use in an alcohol-dependent patient; poor diet control in a patient with diabetes … Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence.
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - Are pre-treatment tests and evaluations needed to safely provide a potentially toxic therapy? … Even new treatments and technologies within a discipline will continue to press physicians to acquire … ( 3,13 )
Case & Commentary: Part 2
Prior to therapy, the physician did not refer the patient for … Treatment was continued without change. … Effect of board certification on antihypertensive treatment intensification in patients with diabetes
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024 … Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. … The Case
A 16-year-old girl with type 1 diabetes presented to the emergency department (ED) complaining … Despite aggressive treatment with insulin drip at a basal rate of 0.1 unit/kg, her
blood glucose remained … The Commentary
By Brittany Newton, PharmD, and Roslyn Seitz, MPH, MSN
Treatment of DKA is characterized
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psnet.ahrq.gov/issue/e-prescribing-first-step-improved-safety
February 16, 2011 - May 9, 2014
Chemotherapy medication errors in a pediatric cancer treatment center: prospective
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psnet.ahrq.gov/issue/framing-clinical-information-affects-physicians-diagnostic-accuracy
November 02, 2011 - among ICU patients
December 4, 2019
ASPEN Safe Practices for Enteral Nutrition Therapy … WebM&M Cases
Delay in Appropriate Diagnosis and Treatment
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - The Case
A 62-year-old man with a history of diabetes presented to a rural emergency department (ED … may have additional non-ED responsibilities (such as helping out on a small inpatient unit), making treatment … patients in rural hospitals can enhance the detection of subtle abnormalities and can improve early treatment … Incidence and predictors of silent myocardial infarction in type 2 diabetes and the effect of fenofibrate … : an analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - The Commentary In the case above, a patient's nonadherence to dialysis and receipt of pain treatment … This case, however, does illustrate many of the complexities regarding optimal treatment of chronic pain … Processes for prescribing and managing opioid treatment can be implemented in dialysis units to mitigate … Opioid dependence and addiction during opioid treatment of chronic pain. Pain. 2007;129:235-255. … Changes Safety
March 1, 2017
Making surgical wards safer for patients with diabetes
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes … Because IV thrombolytics have a narrow therapeutic window, practitioners must provide rapid assessments … Studies have
demonstrated that earlier treatment with thrombolytics leads to better functional outcomes … One
potential way of increasing diagnostic accuracy and reducing the treatment of mimics when neurological … Association of outcome with early stroke treatment: pooled
analysis of ATLANTIS, ECASS, and NINDS rt-PA
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Scale (COWS) and pharmacologic treatments. … facilities (or in licensed opioid agonist therapy [OAT] programs). … to longer term
maintenance therapy using buprenorphine or methadone. … unhealthy behavior (e.g., alcohol use
in an alcohol-dependent patient; poor diet control in a patient with diabetes … Counseling plus buprenorphine-naloxone maintenance
therapy for opioid dependence.
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - was notable for having had an aortic valve replaced with a titanium valve and chronic management at a therapeutic … atrial fibrillation, history of a stroke or TIA, or risk factor(s) for stroke, such as hypertension, diabetes … the emergency department (ED), only that she was chronically anticoagulated using warfarin “with a therapeutic … Without administering such a bolus, it may take 12-24 hours to reach a therapeutic heparin level. … Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - people’s lives, sending them out to do things they don’t need to do, and avoid unnecessary tests or
treatments … For
example, a great way to think about using an EHR is to create registries of patients with diabetes … to
translate that complex medical jargon related to national guidelines around preventive care and treatments … A lot of quality metrics have to do with tests: checking cholesterol, checking A1Cs for diabetes, and … had the patient’s name and their date of birth,
and then it was a line with a date, a diagnosis, a treatment
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Errors in care
and adverse events associated with health literacy include mistakes in diabetes management … medications for children;3
incorrect use of inhalers and aerosol medications;4 falls; delays in receiving treatment … The role of health literacy in diabetes knowledge, self-care, and
glycemic control: a meta-analysis.
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psnet.ahrq.gov/issue/alternative-medications-medications-use-high-risk-medications-elderly-and-potentially-harmful
April 27, 2011 - avoiding these medications is a quality measure, it is a priority for health systems to employ alternative treatments
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - The Case
A 58-year-old man with a past medical history of seizures, meningioma, type 2 diabetes mellitus … activator) for intravenous thrombolysis in acute ischemic stroke and, more
recently, endovascular therapy … to be at their neurological baseline.1 This extended time window
primarily applies to endovascular therapy … The therapeutic time window for acute ischemic stroke is relatively narrow, and any
delays in diagnosis … window for endovascular treatment.
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - Are pre-
treatment tests and evaluations needed to safely provide a potentially toxic therapy? … Even new treatments and technologies within a discipline will continue to press physicians to acquire … Treatment was continued without change. … ; (ii) no genotype performed to help guide length of
therapy; (iii) no baseline laboratory tests to … Effect of board certification on
antihypertensive treatment intensification in patients with diabetes
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - This helped them overcome personal health barriers, so they’d be ready to get treatment. … We screen for substance use and assess readiness for treatment as part of the mental health assessment … pain and they have a variety of interventions, mental health and acupuncture, a variety of integrative therapies … about how group visits could play an important part of chronic disease management and substance use treatment … TFFRS – Diabetes prevention: Interventions engaging community health workers.
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - people’s lives, sending them out to do things they don’t need to do, and avoid unnecessary tests or treatments … For example, a great way to think about using an EHR is to create registries of patients with diabetes … to translate that complex medical jargon related to national guidelines around preventive care and treatments … A lot of quality metrics have to do with tests: checking cholesterol, checking A1Cs for diabetes, and … TFFRS – Diabetes prevention: Interventions engaging community health workers.