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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end … deep paralysis is requested for this type of procedure, additional sugammadex must be given at the end … Reduce the dose of rocuronium in patients with renal and hepatic impairment The amount of sugammadex … needed at the end of the procedure depends on the total amount as well as the timing of the rocuronium … Is it always necessary to reverse the neuromuscular blockade at the end of surgery?
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - When kidney damage becomes severe enough, patients may be diagnosed with end-stage kidney disease (ESKD … training and ongoing communication between the patient and the care team. 7 Mitigating Safety Risks in End-Stage … Could you start out by describing your current role and summarize how you engage with ESRD [end-stage … renal disease] caregivers? … KH : That is a great place to end.
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - Case & Commentary Part 1 A 54-year-old man with hypertension, diabetes, and end-stage renal disease on … developing a fatal arrhythmia due to his acute myocardial infarction and co-morbid conditions (diabetes, end-stage … renal failure).
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
February 01, 2003 - However, despite a rise in the end-tidal CO2 to 70mm Hg, spontaneous respirations did not return. … respiratory depression
Risk Factors for Prolonged Apnea
Hyperventilated patients
Extremes of age
Renal … syringe or drug ampoule swap (7%).1
Leape and colleagues found that 40 of 334 errors (12%) at the stage
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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - She had a past medical history of end-stage renal disease (on hemodialysis 3 times/week), hypertension … Since many medications are excreted by the kidneys, patients with renal dysfunction are at even higher
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - The Case A 55-year-old woman with end stage renal disease requiring hemodialysis and coronary artery … Hour Prior to Surgical Incision Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End … October 3, 2017
Stories from the sharp end: case studies in safety improvement.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - exposure to heparin in individuals with HIT
Case: Hidden Heparins
A patient with a history of end-stage … renal disease requiring hemodialysis was admitted for evaluation of non-healing ulcers and leukocytosis … be obtained 4 hours after starting the infusion and at least daily during treatment Patients with renal
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - psnet.ahrq.gov/primer/digital-health-literacy
https://psnet.ahrq.gov/issue/health-literacy-prescription-end-confusion … errors, communication errors, patients with serious conditions including diabetic ketoacidosis and end … stage renal disease. … help patients to achieve health literacy:
Ensuring all patients feel welcomed and comfortable at each stage
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status … The patient had end-stage liver disease and was not following his home treatment regimen. … Initial therapy was to carefully correct his acute renal injury while using lactulose to improve his
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - Validity of a clinical decision rule-based alert system for drug dose adjustment in patients with renal … WebM&M Cases
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage … Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal … The patient had end-stage liver disease and was not following his home
treatment regimen. … Initial therapy was to carefully correct his acute renal injury while using lactulose to improve his
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psnet.ahrq.gov/issue/healthcare-411-making-hospital-discharges-safer-seniors
February 24, 2021 - February 25, 2015
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
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psnet.ahrq.gov/issue/medical-office-comparative-database-submission-information
February 24, 2021 - February 25, 2015
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - alarm fatigue
3
Case: Harm From Alarm Fatigue
A 54-year-old man with hypertension, diabetes, and end-stage … renal disease on hemodialysis was admitted to the hospital with chest pain.
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psnet.ahrq.gov/node/73145/psn-pdf
April 28, 2021 - the Medical Director for Satellite
Health Care and as a member of the Medical Advisory Board for Nx Stage … Could you start out by describing your current role and
summarize how you engage with ESRD [end-stage … renal disease] caregivers? … ’re scaling this where we can make this more attainable for patients, but I think it does start and end … hhs-launches-president-trump-advancing-american-kidney-health-initiative.html
KH: That is a great place to end
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psnet.ahrq.gov/issue/healthcare-411-provider-insider-medical-handoffs
October 18, 2006 - February 4, 2015
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - October 18, 2023
Patient safety in palliative care at the end of life from the perspective … WebM&M Cases
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage … Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) with a history of end … -
stage renal disease (ESRD), hypertension, poorly controlled type 1 diabetes complicated by
polyneuropathy … beta-hydroxybutyrate levels tend to be lower among ESRD patients with DKA
than among patients with preserved renal
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - errors , communication errors , patients with serious conditions including diabetic ketoacidosis and end … stage renal disease . … help patients to achieve health literacy: Ensuring all patients feel welcomed and comfortable at each stage
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney … introduced, health care organizations need to monitor implementation and effectiveness.( 4 ) To this end