-
psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - This is an important concept to recall—failure to do so might leave caregivers doubting their diagnosis … monitoring would be to require that it be reported in patients with hypoalbuminemia or end-stage renal failure
-
psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - Central vein catheterization: failure and complication rates by three percutaneous approaches.
-
psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - October 31, 2012
Failure to notify reportable test results: significance in medical malpractice
-
psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - March 18, 2009
WebM&M Cases
Failure to Report
March
-
psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - Precipitating factors for DKA include infections, new-onset diabetes, insulin pump failure or missed
-
www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-digital.html
May 01, 2024 - telemedicine visits on hospital admissions for ambulatory care-sensitive conditions (such as congestive heart failure
-
psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - body mass index (BMI) less than 20, liver disease (including passive congestion from congestive heart failure
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/simulation/simulation-issue-brief.pdf
July 01, 2024 - Areas appropriate for integration
of simulation include failure modes and effects
analysis (FMEA),18 … Failure modes and effects analysis based on in
situ simulations: a methodology to improve understanding
-
psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - federal government and many payers seek to subsidize and/or reward physicians' EMR use and to penalize "failure
-
psnet.ahrq.gov/node/33680/psn-pdf
March 22, 2009 - For a patient with heart failure, this means making sure I really understand whether this person
has
-
psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - June 1, 2012
WebM&M Cases
Communication Failure—Who's
-
psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - There is no process for collaborative failure analysis.
-
psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - If I have 100
congestive heart failure patients weighing themselves every morning and we're looking
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-facguide.html
March 01, 2017 - Failure to plan for and provide the necessary organizational infrastructure and resources can be a barrier
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-facilitator-guide.docx
June 01, 2021 - Slide 2
Communication Errors Can Have Disastrous Effects
SAY:
Failure to communicate effectively
-
psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - March 29, 2023
WebM&M Cases
Open wider: Failure
-
digital.ahrq.gov/sites/default/files/docs/page/final-kaushal-story-7-6-12.pdf
June 16, 2021 - . §†
NQF
5
Percentage of patients with heart failure who also have paroxysmal or chronic atrial fibrillation
-
psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Extra dose ADEs are commonly associated with a failure of communication and/or missing information.
-
www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
July 01, 2018 - Communication failure: basic components, contributing factors, and the call for structure.
-
psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Wrong Medication
April 1, 2010
WebM&M Cases
Failure