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psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
September 01, 2011 - September 1, 2011
WebM&M Cases
DRESSed for Failure
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integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/obtain-training-and-support-providers-and-staff/clinicwide-orientation-oud-treatment
January 01, 2019 - As with any chronic disease, relapse is common and is not a sign of failure but rather the need to adjust
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Physician failure to appreciate the high-risk nature of
anticoagulation, especially in the setting of
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - Because emergency care requires the cooperation of
multiple physicians, failure to accurately transfer
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - human-computer
interaction.(11) Using CPOE systems is the safest way to order drugs.(12) However, failure
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - each issue may
not present a significant risk on its own, the convergence of the multiple potential failure
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psnet.ahrq.gov/node/49430/psn-pdf
January 01, 2004 - The decision of the charge nurse may have represented a
failure of communication between the two nurses
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - catastrophic accident, a faulty "first story" often emerges
that blames the 'sharp end' worker for a failure
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Danger in the guise of safety: near miss as a system failure? A success? Or a
good nurse at work?
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - The
most durable fix for this failure of the human mind will likely be a widespread revision of the
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - The patient was subsequently transferred to the coronary care unit (CCU) with
respiratory failure requiring
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
The Case
A 76-year-old man with a history of heart failure
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psnet.ahrq.gov/node/33835/psn-pdf
June 01, 2017 - We've done a little bit of work around failure to rescue
as an indicator.
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - considerably.(9) Certain comorbidities
that impact on mortality (such as morbid obesity, dementia, and heart failure
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - there was a
lack of understanding regarding the appropriate use of long-acting opiates, as well as a failure
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - The Commentary
While it is tempting to blame the physician for a lack of vigilance or the nurse for failure
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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - -
empty" mindset characteristic of a high reliability organization (15) reminds us that an initial failure
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - Failure to follow this regimen or episodic dosing, or not using the standardized induction
sequence
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psnet.ahrq.gov/node/49683/psn-pdf
April 01, 2013 - The failure to recognize the importance of changing the psychiatric medication by the non-
psychiatric
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - medicines or for cases of severe
hypokalemia causing cardiac arrhythmias, quadriplegia, respiratory failure