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psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and
June 23, 2021 - Study
Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.
Citation Text:
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospectiv…
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psnet.ahrq.gov/issue/patient-safety-dialysis-access
September 29, 2017 - Book/Report
Patient Safety in Dialysis Access.
Citation Text:
Patient Safety in Dialysis Access. Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
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psnet.ahrq.gov/issue/safe-use-cellular-telephones-hospitals-fundamental-principles-and-case-studies
August 04, 2021 - Commentary
Safe use of cellular telephones in hospitals: fundamental principles and case studies.
Citation Text:
Cohen T, Ellis WS, Morrissey JJ, et al. Safe use of cellular telephones in hospitals: fundamental principles and case studies. J Healthc Inf Manag. 2005;19(4):38-48.
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psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - This is extremely relevant for patients with chronic kidney
disease, where the use of a PICC has been … We also built in evidence for use of
PICCs in chronic kidney disease. … We want to encourage avoidance of PICC use in chronic kidney disease,
so our Epic orderset pulls in
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and chronic kidney … disease was transferred to a referral hospital for percutaneous coronary intervention after presenting … rather than jugular in adult patients [1B] Use fistula or graft in chronic kidney … disease instead of central venous catheter [1A] Use ultrasound to reduce
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic kidney … disease, atrial fibrillation, and type 2 diabetes mellitus presented to the emergency department (ED
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psnet.ahrq.gov/issue/impact-automated-alerts-discharge-opioid-overprescribing-after-general-surgery
September 29, 2017 - September 15, 2021
Chronic kidney disease adversely influences patient safety.
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psnet.ahrq.gov/issue/40-years-behind-mask-safety-revisited
January 13, 2012 - WebM&M Cases
Complications of Vascular Access Procedures in Patients with Kidney … Disease
November 27, 2019
The Helsinki Declaration on Patient Safety in Anaesthesiology
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psnet.ahrq.gov/issue/nursing-strategies-safeguard-covid-19-patients-harm-intensive-care-unit
July 31, 2013 - Commentary
Nursing strategies to safeguard COVID-19 patients from harm in the intensive care unit.
Citation Text:
Shiner D, Bock B, Simpson C, et al. Nursing strategies to safeguard COVID-19 patients from harm in the intensive care unit. Crit Care Nurs Q. 2021;45(1):13-21. doi:10.1097/cn…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - This is extremely relevant for patients with chronic kidney disease, where the use of a PICC has been … We also built in evidence for use of PICCs in chronic kidney disease. … We want to encourage avoidance of PICC use in chronic kidney disease, so our Epic orderset pulls in GFR
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psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
May 03, 2023 - Newspaper/Magazine Article
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
Citation Text:
Latest heparin fatality speaks loudly—what have you done to stop the bleeding? ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - and possibly miscommunication regarding the timing of prior insulin doses.1 Patients with chronic kidney … disease (CKD) are in a chronic state of metabolic acidosis, which makes diagnosing DKA challenging.
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - paroxysmal atrial fibrillation, coronary artery
disease, congestive heart failure, stage I chronic kidney … disease
and gout presented for a total hip replacement.
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - WebM&M Cases
Complications of Vascular Access Procedures in Patients with Kidney … Disease
November 27, 2019
Cost implications of actual and potential adverse
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psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings
August 10, 2022 - Study
Patient safety culture in nephrology nurse practice settings: initial findings.
Citation Text:
Patient safety culture in nephrology nurse practice settings: initial findings. Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.
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psnet.ahrq.gov/issue/risk-misdiagnosis-and-delayed-diagnosis-covid-19-syndemic-approach
November 04, 2020 - Commentary
Risk of misdiagnosis and delayed diagnosis with COVID-19: a syndemic approach.
Citation Text:
Muhrer JC. Risk of misdiagnosis and delayed diagnosis with COVID-19. Nurs Pract. 2021;46(2):44-49. doi:10.1097/01.npr.0000731572.91985.98.
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - The Case A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - and possibly miscommunication regarding the timing of prior insulin doses. 1 Patients with chronic kidney … disease (CKD) are in a chronic state of metabolic acidosis, which makes diagnosing DKA challenging.
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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