-
psnet.ahrq.gov/node/49822/psn-pdf
March 01, 2018 - Because she was
trying to sign out at the end of the day, she did not read the entire report. … A recent study found that 43% of patients whose renal function
merited dose reduction were prescribed … common in elderly patients.(8) DOAC dosing should follow recommended guidelines and take into account
renal … during follow-up, shorten the
time to cancer diagnosis, increase the detection of occult or early-stage … Non-vitamin K antagonist oral
anticoagulant dosing in patients with atrial fibrillation and renal dysfunction
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage … renal disease (status post kidney
transplant), coronary artery disease, and peripheral vascular disease … Surgeons, intensivists, and the covenant of care:
administrative models and values affecting care at the end
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - for
instance, it becomes really authentic when you bring patients in for the development and design stage … It
looks different in end-stage renal disease programs, in primary care, it looks different in the hospital
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case
A 65-year-old man with a history of end stage renal disease, injection drug use, and multiple … Patients often end up admitted to
multiple different hospitals, especially in large urban areas. … steps had been in place, the patient would likely have avoided the unfortunate adverse
event at the end
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - 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/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - had a past medical history of morbid obesity, hypertension, heart failure, chronic kidney disease (stage … Methods such as continuous oximetry, end-tidal carbon dioxide (ETCO2) monitoring, and acoustic respiratory … 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/web-mm/hidden-heparins-hit-happens
March 27, 2024 - Case & Commentary: Part 1
A patient with a history of end-stage renal disease requiring hemodialysis … •
Patients with renal insufficiency: initial bolus = 0.2 mg/kg. … WebM&M Cases
A framework for assessing reasoning about controversial end-of-life
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - alcoholism, human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS), chronic renal … – Stage III includes the development of sensory abnormalities, motor
weakness, and bowel or bladder … – Stage IV is defined by paralysis. … – Advanced neurologic deficits may include paraparesis and quadriparesis,
but these are late-stage … – When abnormalities are present, they are non-specific, most commonly
bony end-plate erosion, degenerative
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - The Case A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis) … The reader then acts as a ledger so that at the end of the case all sponges scanned in have to be scanned
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage … renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstructive, multi-vessel … The reader then acts as a ledger so
that at the end of the case all sponges scanned in have to be scanned
-
psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - Because she was trying to sign out at the end of the day, she did not read the entire report. … A recent study found that 43% of patients whose renal function merited dose reduction were prescribed … common in elderly patients.( 8 ) DOAC dosing should follow recommended guidelines and take into account renal … cancers during follow-up, shorten the time to cancer diagnosis, increase the detection of occult or early-stage … Non-vitamin K antagonist oral anticoagulant dosing in patients with atrial fibrillation and renal dysfunction
-
psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Case #2: A 74-year-old man with a history of hypertensive end-stage renal disease and significant cardiac … disease, including current antibiotic treatment for bacterial endocarditis, was seen in the outpatient renal
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - WebM&M Cases
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage … Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
-
psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - //psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage … renal disease on hemodialysis was awaiting a kidney
transplant. … introduced, health care organizations need to monitor
implementation and effectiveness.(4) To this end
-
psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - alcoholism, human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS), chronic renal … Stage II progresses to include stabbing or shooting radicular pain, nuchal rigidity/neck stiffness, and … all symptoms may be present at each stage. … When
abnormalities are present, they are non-specific, most commonly bony end-plate erosion, degenerative … It relies on the presence of neurologic deficit, which is a late-
stage finding in cases of SEA and
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - alcoholism, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), chronic renal … Stage II progresses to include stabbing or shooting radicular pain, nuchal rigidity/neck stiffness, and … Stage IV is defined by paralysis. 19 SEA does not universally progress in this manner, however, and … not all symptoms may be present at each stage. … When abnormalities are present, they are non-specific, most commonly bony end-plate erosion, degenerative
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - However, despite a rise in the end-tidal CO2 to 70mm Hg, spontaneous respirations did not return. … occurs more often in hyperventilated patients; neonates; elderly patients; patients with compromised renal … therefore more likely to experience adverse events.( 9 ) Documenting errors at the administration stage … syringe or drug ampoule swap (7%).( 12 ) Leape and colleagues found that 40 of 334 errors (12%) at the stage … Medication errors at the administration stage in an intensive care unit.
-
psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - Medication
errors are most common at the ordering or prescribing stage. … Decreased
hepatic blood flow and hepatic function reduces medication metabolism, and reduced renal function … , transitioning between parenteral and oral medications, and the utilization of outdated
weight or renal … Stage 1 1: 1–3. http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/downloads
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - The Case A 65-year-old man with a history of end stage renal disease, injection drug use, and multiple … Patients often end up admitted to multiple different hospitals, especially in large urban areas. … steps had been in place, the patient would likely have avoided the unfortunate adverse event at the end
-
psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - Case #2: A 74-year-old man with a history of hypertensive end-stage renal disease and significant cardiac … disease, including current antibiotic treatment for bacterial endocarditis, was seen in the outpatient renal