-
psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - administration of DDAVP (desmopressin
acetate) and free-water boluses given by percutaneous endoscopic gastrostomy … (PEG) tube to maintain a
normal sodium level. … Due to PEG tube dysfunction, the patient was unable to give herself free-water
boluses for the 2 days … staff team struggled with her sodium management, trying to
balance the DDAVP and the free water by PEG tube
-
psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - danger-discharge-summaries-abbreviations-create-confusion-both-author-and-recipient
https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication … web-mm/critical-echocardiogram-result-lost-follow
https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
-
ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.html
January 01, 2013 - IV/Tube
Yes
No
IV (central line, peripheral)
Bladder catheter
Gastrostomy … or other feeding tube
Pneumatic compression> stockings
Other:
-
www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/coaching.html
December 01, 2013 - immunizations, breastfeeding or specialized bottle feeding, managing breathing, bronchopulmonary dysplasia, or gastrostomy … (tube or button).
-
www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/coaching.html
December 01, 2013 - immunizations, breastfeeding or specialized bottle feeding, managing breathing, bronchopulmonary dysplasia, or gastrostomy … (tube or button).
-
psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - administration of DDAVP (desmopressin acetate) and free-water boluses given by percutaneous endoscopic gastrostomy … (PEG) tube to maintain a normal sodium level. … Due to PEG tube dysfunction, the patient was unable to give herself free-water boluses for the 2 days … staff team struggled with her sodium management, trying to balance the DDAVP and the free water by PEG tube
-
psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Similarly, Enfit connectors and syringes for oral/g-tube/NG tube help to prevent inadvertent connection … 15, 2020
WebM&M Cases
The Risks of a Malpositioned Gastrostomy … Tube and Poor Communication
November 29, 2023
Development of a pediatric adverse
-
psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - At baseline he had some cognitive deficits and
received his nutrition through a percutaneous gastrostomy … (feeding) tube. … basal coverage, a short-acting insulin (such as regular
insulin every 6 hours) to cover for continuous tube … redesigned or protocols or order sets adjusted
to ensure reliable use.(10)
In this case, the patient's tube … If a patient is receiving insulin to match an expected caloric intake, stopping nutrition
or tube feeding
-
psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - At baseline he had some cognitive deficits and received his nutrition through a percutaneous gastrostomy … (feeding) tube. … basal coverage, a short-acting insulin (such as regular insulin every 6 hours) to cover for continuous tube … hard-to-control blood sugars including an active infection, acute kidney injury, variable oral intake, and tube … If a patient is receiving insulin to match an expected caloric intake, stopping nutrition or tube feeding
-
psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - He received bolus feedings through a gastrostomy tube and required occasional suctioning of his tracheostomy
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2016_ED_MaskedStats.PDF
January 01, 2016 - 69: Esophageal dilatation 744 0.00
70: Upper gastrointestinal endoscopy, biopsy 15,404 0.05
71: Gastrostomy … detoxification 499 0.00
220: Ophthalmologic and otologic diagnosis and treatment 898 0.00
221: Nasogastric tube
-
www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/nicu/coaching.html
December 01, 2013 - immunizations, breastfeeding or specialized bottle feeding, managing breathing, bronchopulmonary dysplasia, or gastrostomy … (tube or button).
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2011v2_MaskedStats_ED.PDF
November 03, 2014 - 0.00
69: Esophageal dilatation 457 0.00
70: Upper gastrointestinal endoscopy, biopsy 9,957 0.04
71: Gastrostomy … detoxification 1,967 0.01
220: Ophthalmologic and otologic diagnosis and treatment 486 0.00
221: Nasogastric tube … 69: Esophageal dilatation 798 0.00
70: Upper gastrointestinal endoscopy; biopsy 12,816 0.05
71: Gastrostomy … detoxification 3,055 0.01
220: Ophthalmologic and otologic diagnosis and treatment 126 0.00
221: Nasogastric tube
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2012_MaskedStats_ED.PDF
January 01, 2012 - 0.00
69: Esophageal dilatation 455 0.00
70: Upper gastrointestinal endoscopy, biopsy 9,817 0.04
71: Gastrostomy … detoxification 1,257 0.00
220: Ophthalmologic and otologic diagnosis and treatment 1,240 0.00
221: Nasogastric tube … 69: Esophageal dilatation 879 0.00
70: Upper gastrointestinal endoscopy; biopsy 14,495 0.05
71: Gastrostomy … detoxification 456 0.00
220: Ophthalmologic and otologic diagnosis and treatment 419 0.00
221: Nasogastric tube
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2011_MaskedStats_ED.PDF
January 01, 2011 - 69: Esophageal dilatation 525 0.00
70: Upper gastrointestinal endoscopy, biopsy 11,036 0.04
71: Gastrostomy … detoxification 1,967 0.01
220: Ophthalmologic and otologic diagnosis and treatment 488 0.00
221: Nasogastric tube … 69: Esophageal dilatation 1,174 0.00
70: Upper gastrointestinal endoscopy; biopsy 20,540 0.08
71: Gastrostomy … detoxification 5,920 0.02
220: Ophthalmologic and otologic diagnosis and treatment 137 0.00
221: Nasogastric tube
-
hcup-us.ahrq.gov/toolssoftware/ccs10/CCSCategoryNames(FullLabels).pdf
January 18, 2017 - information from
procedures)
69 Esophageal dilatation
70 Upper gastrointestinal endoscopy; biopsy
71 Gastrostomy … rehabilitation/detoxification
220 Ophthalmologic and otologic diagnosis and treatment
221 Nasogastric tube … system
9.1 Therapeutic procedures on the esophagus
9.2 Upper gastrointestinal endoscopy; biopsy [70]
9.3 Gastrostomy … detoxification [219]
16.31 Ophthalmologic and otologic diagnosis and treatment [220]
16.32 Nasogastric tube
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2014_MaskedStats_ED.PDF
January 01, 2014 - 69: Esophageal dilatation 625 0.00
70: Upper gastrointestinal endoscopy, biopsy 11,279 0.04
71: Gastrostomy … detoxification 37 0.00
220: Ophthalmologic and otologic diagnosis and treatment 1,389 0.01
221: Nasogastric tube … 69: Esophageal dilatation 1,084 0.00
70: Upper gastrointestinal endoscopy; biopsy 11,556 0.04
71: Gastrostomy … detoxification 309 0.00
220: Ophthalmologic and otologic diagnosis and treatment 200 0.00
221: Nasogastric tube
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2013_MaskedStats_ED.PDF
January 01, 2013 - 0.00
69: Esophageal dilatation 519 0.00
70: Upper gastrointestinal endoscopy, biopsy 9,821 0.04
71: Gastrostomy … detoxification 2,560 0.01
220: Ophthalmologic and otologic diagnosis and treatment 477 0.00
221: Nasogastric tube … 69: Esophageal dilatation 846 0.00
70: Upper gastrointestinal endoscopy; biopsy 13,567 0.05
71: Gastrostomy … Frequency Percent
220: Ophthalmologic and otologic diagnosis and treatment 288 0.00
221: Nasogastric tube
-
hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2010_MaskedStats_ED.PDF
January 01, 2010 - 12:45 Monday, October 29, 2012 6
Frequency Distribution for CPTCCS1
CPTCCS1 Frequency Percent
71: Gastrostomy … detoxification 307 0.00
220: Ophthalmologic and otologic diagnosis and treatment 479 0.00
221: Nasogastric tube … 69: Esophageal dilatation 952 0.00
70: Upper gastrointestinal endoscopy; biopsy 12,386 0.05
71: Gastrostomy … detoxification 524 0.00
220: Ophthalmologic and otologic diagnosis and treatment 563 0.00
221: Nasogastric tube
-
psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - He received bolus feedings through a gastrostomy tube
and required occasional suctioning of his tracheostomy