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psnet.ahrq.gov/issue/operating-room-fire-hospital-burns-patient-prompts-changes
September 21, 2022 - March 20, 2013
UTMC nurse tossed out kidney, ruined it.
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psnet.ahrq.gov/issue/reducing-preventable-medication-safety-events-recognizing-renal-risk
June 27, 2011 - This study suggests that routine assessment of kidney function can reduce the risk of medication-related
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psnet.ahrq.gov/node/44180/psn-pdf
June 21, 2015 - medicares-decision-withhold-payment-hospital-errors-devil-details
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
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psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery
April 21, 2021 - Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - Initial laboratory tests, including kidney function, and a non-contrast cranial
computed tomography … routinely perform CT angiography during stroke alerts due to
concerns about causing contrast-related acute kidney … without waiting for serum creatinine results
when there is suspicion of an LVO, no known history of kidney … For patients with no known kidney disease and suspected LVO stroke, CT angiography and
perfusion imaging
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Low solute intake also causes low renal medullary concentration, leading to inability of the kidneys … Am J Kidney Dis. 2013;61(4):571-8.
Medication Safety Self-Assessment or High-Alert Medications. … the Same Author(s)
WebM&M Cases
Delayed Diagnosis of Kidney
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psnet.ahrq.gov/issue/empowered-improve
November 10, 2011 - October 26, 2011
Chronic kidney disease adversely influences patient safety.
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psnet.ahrq.gov/issue/fires-during-surgeries-bigger-risk-thought
August 24, 2016 - August 21, 2013
UTMC nurse tossed out kidney, ruined it.
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psnet.ahrq.gov/issue/technology-has-transformed-va
October 07, 2008 - January 10, 2007
Scathing report on Kaiser kidney program.
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psnet.ahrq.gov/issue/maternity-ward-highland-under-fire-patients
December 12, 2018 - December 22, 2010
Scathing report on Kaiser kidney program.
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psnet.ahrq.gov/issue/unpacking-complexity-covid-19-fatalities-adverse-events-contributing-factors-single-center
January 25, 2023 - other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - • Initial laboratory tests, including kidney function, and a non-contrast
cranial computed tomography … perform CT
angiography during stroke alerts due to concerns about causing
contrast-related acute kidney … without waiting
for serum creatinine results when there is suspicion of an LVO, no
known history of kidney … Take-Home Points (3)
38
• For patients with no known kidney disease and suspected LVO stroke,
CT angiography
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - Initial laboratory tests, including kidney function, and a non-contrast cranial computed tomography ( … routinely perform CT angiography during stroke alerts due to concerns about causing contrast-related acute kidney … without waiting for serum creatinine results when there is suspicion of an LVO, no known history of kidney … For patients with no known kidney disease and suspected LVO stroke, CT angiography and perfusion imaging
-
psnet.ahrq.gov/web-mm/one-dose-two-errors
September 29, 2017 - The consulting nephrologist felt that amphotericin toxicity was the most likely cause of the acute kidney … Although she was not dialysis-dependent when discharged from the hospital, her kidney function never … system (CDSS) can improve antimicrobial selection and dosing and can reduce adverse events, including kidney
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psnet.ahrq.gov/issue/critical-incident-monitoring-anaesthesia
September 04, 2024 - Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney
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psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings
August 10, 2022 - Related Resources
Clinical characteristics and short-term outcomes of acute kidney
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psnet.ahrq.gov/issue/optimizing-patient-safety-during-hemodialysis
October 28, 2020 - Related Resources
WebM&M Cases
Delayed Diagnosis of Kidney
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psnet.ahrq.gov/issue/error-detection-and-recovery-dialysis-nursing
November 16, 2022 - Related Resources
WebM&M Cases
Delayed Diagnosis of Kidney
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - The Case
An 83-year-old man with chronic kidney disease and end-stage congestive heart failure (CHF) … Adv Chronic Kidney Dis. 2007;14:402-408. [go to PubMed]
3. … Palliative and end-of-life care issues in chronic kidney disease. … Adverse effects in hospice patients with chronic kidney
disease receiving hydromorphone.
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psnet.ahrq.gov/issue/simple-surgery-harrowing-complications
November 07, 2012 - October 31, 2012
UTMC nurse tossed out kidney, ruined it.