-
psnet.ahrq.gov/issue/hardwiring-safety-computer-system-one-hospitals-actions-provide-technology-support-u-500
February 24, 2016 - 2018
Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment … April 23, 2014
Medication errors common for hospital diabetes.
-
psnet.ahrq.gov/issue/regret-among-primary-care-physicians-survey-diagnostic-decisions
November 13, 2019 - , regular blood glucose tests may have prevented a stroke that likely occurred due to decompensated diabetes … impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment … sets of criteria for potentially inappropriate prescribing in older people to identify inadequate drug treatment
-
psnet.ahrq.gov/issue/medication-sharing-storage-and-disposal-practices-opioid-medications-among-us-adults
March 30, 2022 - Same Author(s)
Effects of state opioid prescribing laws on use of opioid and other pain treatments … November 14, 2018
Type 1 diabetes defined by severe insulin deficiency occurs after 30 … years of age and is commonly treated as type 2 diabetes.
-
psnet.ahrq.gov/issue/frequency-failure-inform-patients-clinically-significant-outpatient-test-results
April 24, 2018 - interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes … Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. … March 12, 2014
The frequency of missed test results and associated treatment delays in
-
psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - creates a seamless, legible, comprehensive, and enduring record of a
patient's health history and treatment … Similarly, in a
case study of electronic prescribing for patients with diabetes in a safety net clinic … recommended universal
medication scheduling practices for instructing patients when to take their diabetes … health literacy and low
English proficiency and can thereby reduce mistakes in adherence to prescribed therapy … of interface may result in errors in clinical
decision making and contribute to errors or delays in treatment
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - patient safety oversight
*
*
Case: Dangerous Dialysis
A 48-year-old man with a long history of diabetes … National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda … Prevalence of Errors
One retrospective study found 1 error or adverse event for every 733 dialysis treatments … a mistake or error in a dialysis treatment in the last 3 months
See Notes for references … Characteristics and treatment of patients not reusing dialyzers in reuse units.
-
psnet.ahrq.gov/issue/patient-safety-culture-home-care-experiences-home-care-nurses
July 02, 2008 - Safety risks associated with physical interactions between patients and caregivers during treatment … August 18, 2010
Insulin treatment as a tracer for identifying latent patient safety risks … in home-based diabetes care.
-
psnet.ahrq.gov/issue/homenet-ensuring-patient-safety-medical-device-use-home
June 18, 2014 - Safety risks associated with physical interactions between patients and caregivers during treatment … February 3, 2010
Insulin treatment as a tracer for identifying latent patient safety … risks in home-based diabetes care.
-
psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - or gestational diabetes. … diet, exercise, and glucose monitoring should begin at diagnosis for all patients and may be the only
therapy … case
presentation, is available only for subcutaneous administration; is indicated for adjunctive therapy … She also complained that her acne had worsened, and she requested treatment for it. … American Diabetes Association. Standards of medical care in diabetes—2009.
-
psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - an active role in their pharmaceutical care
Case & Commentary: Part 1
A 79-year-old man with diabetes … Starting therapy in an elderly patient with a single agent is generally a safer strategy, and many patients … older patients, including (i) the “start low and go slow” philosophy when initiating and intensifying a therapeutic … However, every effort must be taken to provide elderly patients with the full benefits of an optimal therapeutic … The patient was readmitted to hospital and given fluids intravenously; the antibiotic therapy was stopped
-
psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - The Case
A 76-year-old woman with history of hypertension, diabetes, and advanced dementia was brought … The committee believed
the overly aggressive treatment had led to the patient's death. … These treatments are costly, prolong hospital length of stay, and often are
continued as an outpatient … The patient might have received hydration and physical therapy, and
perhaps the providers could have … coronary artery disease using CT
angiography on mortality and cardiac events in high-risk patients with diabetes
-
psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - The Case
A 48-year-old man with a long history of diabetes and end-stage renal disease (ESRD) on hemodialysis … and then reusing it for subsequent treatments in the same patient. … per day, or more than 500 treatments per week. … to limit the number of patients initiating therapy at the same time may all reduce the potential for … National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Bethesda
-
psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - The Case
A 76-year-old woman with history of hypertension, diabetes, and advanced dementia was brought … The committee believed the overly aggressive treatment had led to the patient's death. … These treatments are costly, prolong hospital length of stay, and often are continued as an outpatient … coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes … March 15, 2023
To expand the evidence base about harms from tests and treatments.
-
psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - The Case A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank … The patient responded quickly to treatment with D50 and had a full recovery once the error in insulin … ACE/ADA Task Force on Inpatient Diabetes. … diabetes and glycemic control: a call to action. … Diabetes Care. 2006;29:1955-1962. [go to PubMed] 2. Englesbe MJ, Pelletier SJ, Magee JC, et al.
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - often tests are missed in the outpatient setting
In one study, 15% of abnormal tests suggestive of diabetes … were never followed up by clinicians; about 9% of these patients had unrecognized (and untreated) diabetes … Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment … 2007;30:338-343. http://www.ncbi.nlm.nih.gov/pubmed/17873665
16
Ability to order additional tests or treatments … Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment
-
psnet.ahrq.gov/issue/laboratory-test-ordering-and-results-management-systems-qualitative-study-safety-risks
March 16, 2016 - 2016
Root cause analysis reports help identify common factors in delayed diagnosis and treatment … November 14, 2011
The frequency of missed test results and associated treatment delays … February 24, 2011
Patient safety systems in the primary health care of diabetes—a story
-
psnet.ahrq.gov/issue/shifting-risks-night
July 06, 2011 - July 6, 2011
Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis. … 2011
Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment
-
psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Diabetes care guidelines discuss the transition from intravenous (IV) to subcutaneous insulin in patients … with type 2 diabetes admitted with hyperglycemia.(2,3) Blood sugars should be in the target range of … Basal insulin is started before discontinuing the insulin infusion to
allow the former to reach therapeutic … Diabetes Care. 2005;28:2418-2423. [go
to PubMed]
7. Karsh BT. … just-in-time physician
and nurse training on
Glucommander use
Improved handoffs outlining
current treatment
-
psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - The Case
A 48-year-old man with a long history of diabetes and end-stage renal disease (ESRD) on hemodialysis … and then reusing it for subsequent treatments in the same patient. … per day, or more than 500
treatments per week. … to limit the number of patients initiating therapy at the same time may all
reduce the potential for … National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases: Bethesda
-
psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - diabetes management. … We administer injection therapies, including vaccinations, vitamin B12, intramuscular antibiotics and … Finally, we may offer urgent treatments with triptans for acute migraine, albuterol for asthma, epinephrine … Insulin errors and injuries are common among hospitalized patients.( 4-9 ) The risk of treatment-related … A systems approach to reducing errors in insulin therapy in the inpatient setting.