-
psnet.ahrq.gov/node/44633/psn-pdf
November 11, 2015 - protocol emphasized early recognition by nurses and
escalation of care by a nurse practitioner when indicated
-
psnet.ahrq.gov/node/844775/psn-pdf
September 11, 2019 - inappropriate prescribing of opioids (which
includes both prescribing opioids in situations where they are not indicated
-
psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - During the shift
change that morning, the sign-out to the day shift nurse indicated that PICC insertion … However, a survey conducted by
the Institute for Safe Medication Practices in 2017 indicated that for … Despite this standard, surveys have indicated that nearly half
(45%) of all those who receive telephone … respondents to one survey reported that they read back verbal orders
only 1% to 5% of the time, and 9% indicated
-
psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
December 20, 2023 - Analysis of voluntary error reports indicated a decrease in safety incidents at a high-volume radiation
-
psnet.ahrq.gov/issue/potentially-inappropriate-medication-combination-opioids-among-older-dental-patients
March 18, 2020 - Results indicated that a significant proportion of older patients prescribed opioids by their dentist
-
psnet.ahrq.gov/node/34651/psn-pdf
March 04, 2011 - Results indicated a significant number of adverse events in both elderly (>65) and nonelderly patient
-
psnet.ahrq.gov/node/44165/psn-pdf
May 27, 2015 - They found a relatively low incidence of unplanned return to surgery, but their
clinical review indicated
-
psnet.ahrq.gov/issue/ash-clinical-practice-guidelines-venous-thromboembolism
September 14, 2007 - recommendations include low-molecular-weight heparin as the preferred agent when medication prophylaxis is indicated
-
psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - Individual event debriefs with the 16 operating room team members participating in the pilot study indicated
-
psnet.ahrq.gov/node/36315/psn-pdf
July 10, 2008 - A prior study indicated a rate of
approximately 1 case per 112,000 surgeries, but WSPEs may occur in
-
psnet.ahrq.gov/node/38010/psn-pdf
August 27, 2008 - Pilot testing indicated that this tool successfully identified adverse outcomes that had not been
reported
-
psnet.ahrq.gov/node/37040/psn-pdf
April 11, 2011 - The limited prior research in this area indicated that
potential for such under-referral exists.
-
psnet.ahrq.gov/issue/accreditation-council-graduate-medical-education-technical-skills-competency-compliance
November 16, 2022 - Evaluations by participants indicated that they acquired technical experience through repetition in a
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - Associated with abdominal pain, fever, or diarrhea
In these instances, a more thorough evaluation is indicated … should have been documented
Based on the patient's signs and symptoms, abdominal imaging was probably indicated … pain in pregnant patients should begin with ultrasound or MRI, but ionizing imaging that is clearly indicated
-
psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - During the shift change that morning, the sign-out to the day shift nurse indicated that PICC insertion … However, a survey conducted by the Institute for Safe Medication Practices in 2017 indicated that for … Despite this standard, surveys have indicated that nearly half (45%) of all those who receive telephone … respondents to one survey reported that they read back verbal orders only 1% to 5% of the time, and 9% indicated
-
psnet.ahrq.gov/issue/teaching-medical-students-recognise-and-report-errors
March 01, 2023 - Results indicated that education could influence student ability and willingness to recognize and report
-
psnet.ahrq.gov/node/44586/psn-pdf
June 21, 2016 - The analysis indicated that hospitalized patients
experienced 1.3 million fewer HACs over the 3 years
-
psnet.ahrq.gov/node/43729/psn-pdf
November 21, 2017 - Almost half of respondents filed a complaint with an
oversight agency, a much higher proportion than indicated
-
psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - comfort care and later died
Case Details
8
• During the post-mortem review:
– Medical records indicated … weight heparin17
High-Risk Medications: Anticoagulation (2)
• Unclear whether anticoagulation was indicated … support a diagnosis of unstable angina or myocardial infarction and
therefore anticoagulation was not indicated
-
psnet.ahrq.gov/issue/personal-formularies-primary-care-physicians-across-4-health-care-systems
July 10, 2019 - Results indicated wide variability in the number of unique medications at the physician and institution