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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - These domains included lack
of information about the patient, drug stocking and delivery problems, and inadequate
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psnet.ahrq.gov/node/50392/psn-pdf
September 01, 2019 - As we get into more complicated spaces, a binary language around "never" or "always"
is kind of inadequate
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - qualitative study of 12 radiologists at a Swedish university hospital documented delays stemming from either inadequate
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - or contraindicated ones.( 5 ) Some were guilty of the opposite, providing care that was cursory or inadequate
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - site and CSF leak is more likely. 14 Both mechanisms—CSF extravasation into a pseudomeningocele and inadequate … hydrostatic pressures, 52–54 some remain in situ for only 10-14 days; 55 thus, sealants alone may be inadequate
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - 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
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - the PICU patient room, high levels of dust on the bedside T-bar, ceiling tiles and curtains suggested inadequate
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - global pandemic, systems factors such as the availability of personal protective equipment (PPE) and
inadequate
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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:/…
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice.
October 27, 2022
Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
The Case
A 61-year-old woman was placed on bedrest following major surgery. Her posto…
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Double Trouble
September 1, 2005
Gurwitz JH. Double Trouble. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/double-trouble
Case Objectives
Appreciate the incidence of adverse drug events in older persons
List preventative measures that can be used to minimize medication errors in this population
Encourage…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar…
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Googl…
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - site and CSF
leak is more likely.14 Both mechanisms—CSF extravasation into a pseudomeningocele and inadequate … hydrostatic
pressures,52–54 some remain in situ for only 10-14 days;55 thus, sealants alone may be inadequate
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 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
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psnet.ahrq.gov/web-mm/chemotherapy-extravasation
September 24, 2010 - Chemotherapy Extravasation
Citation Text:
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Organizational culture and inadequate
communication were common underlying causes in many reports.2
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - multiple changes to medication regimens ( 1 ), discontinuity of care ( 2 ), short hospitalizations, and inadequate