-
psnet.ahrq.gov/issue/comparison-broselow-tape-measurements-versus-physician-estimations-pediatric-weights
November 15, 2017 - August 29, 2011
Error in body weight estimation leads to inadequate parenteral anticoagulation
-
psnet.ahrq.gov/issue/patient-handoffs-cross-cover-or-night-shift-better
December 07, 2009 - November 28, 2018
Inadequate hand-off communication.
-
psnet.ahrq.gov/issue/what-words-convey-potential-patient-narratives-inform-quality-improvement
August 19, 2015 - September 23, 2020
When mistakes multiply: how inadequate responses to medical mishaps
-
psnet.ahrq.gov/issue/methods-assessing-preventability-adverse-drug-events-systematic-review
July 24, 2013 - Performance of 3 sets of criteria for potentially inappropriate prescribing in older people to identify inadequate
-
psnet.ahrq.gov/issue/multidisciplinary-teamwork-training-program-triad-optimal-patient-safety-tops-experience
February 12, 2018 - July 2, 2014
Consequences of inadequate sign-out for patient care.
-
psnet.ahrq.gov/issue/improving-teamwork-impact-structured-interdisciplinary-rounds-medical-teaching-unit
December 21, 2014 - February 17, 2011
Consequences of inadequate sign-out for patient care.
-
psnet.ahrq.gov/issue/primary-care-physician-communication-hospital-discharge-reduces-medication-discrepancies
May 04, 2010 - March 15, 2023
Inadequate health literacy among paid caregivers of seniors.
-
psnet.ahrq.gov/issue/transfers-patient-care-between-house-staff-internal-medicine-wards-national-survey
August 15, 2018 - November 7, 2012
Consequences of inadequate sign-out for patient care.
-
psnet.ahrq.gov/issue/inappropriate-drug-use-elderly-nationwide-register-based-study
July 09, 2008 - Performance of 3 sets of criteria for potentially inappropriate prescribing in older people to identify inadequate
-
psnet.ahrq.gov/issue/faculty-member-review-and-feedback-using-sign-out-checklist-improving-intern-written-sign-out
February 15, 2017 - January 15, 2014
Consequences of inadequate sign-out for patient care.
-
psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
-
psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
-
psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
-
psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Patients may require assistance in maintaining a patent airway and
spontaneous ventilation may be inadequate … reporting exist including fear of consequences, a culture of
blame, perception of lack of benefit/action, inadequate
-
psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - organizational planning, culture, and collaboration Lack of standardization of practice guidelines Inadequate
-
psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Therefore, inadequate control of maternal BP with oral medications should lead to prompt hospitalization
-
psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - System Factors Faulty data gathering (eg, incomplete history, cursory examination, inadequate
-
psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - System-related causes of medication administration
errors may include inadequate training, distractors
-
psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - timely TPAD
follow-up.(15) Yet relying on individual providers to complete timely TPAD follow-up is inadequate
-
psnet.ahrq.gov/node/45107/psn-pdf
May 09, 2017 - Missing clinical and behavioral health data in a large
electronic health record (EHR) system.
May 9, 2017
Madden JM, Lakoma MD, Rusinak D, et al. Missing clinical and behavioral health data in a large electronic
health record (EHR) system. J Am Med Info Asso. 2016;23(6):1143-1149. doi:10.1093/jamia/ocw021.
https:/…