-
psnet.ahrq.gov/issue/management-operating-room-critical-events
March 27, 2024 - WebM&M Cases
Uterine Artery Injury during Cesarean Delivery Leads
-
psnet.ahrq.gov/issue/latest-heparin-fatality-speaks-loudly-what-have-you-done-stop-bleeding
May 03, 2023 - June 10, 2018
Electronic prescribing vulnerabilities: height and weight mix-up leads
-
psnet.ahrq.gov/issue/shared-mdis-can-cross-contamination-be-avoided
May 03, 2023 - May 3, 2023
Failed check system for chemotherapy leads to pharmacist's "no contest" plea
-
psnet.ahrq.gov/issue/technology-education-and-safety
December 15, 2021 - September 21, 2022
WebM&M Cases
Saline Flush Leads to
-
digital.ahrq.gov/program-overview/research-stories/supporting-health-systems-advancing-care-delivery
January 01, 2023 - Exchange Facilitating data exchange between public health and clinical care information systems leads
-
psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
March 14, 2023 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/safemedicationuseca
October 10, 2012 - September 9, 2015
Selection of incorrect medication pump leads to chemotherapy overdose
-
www.uspreventiveservicestaskforce.org/home/getfilebytoken/p8huvc8UM4WfAnrNAzYnXS
of Harms and Benefits There is inadequate evidence that treatment of screen-detected bladder cancer leads
-
psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - This state of low solute and high free water intake leads to hypotonic hyponatremia resulting in suppression … In patients in this state, administering solute via either isotonic or hypertonic saline leads to rapid … Related Resources
WebM&M Cases
Medication Mix-Up Leads
-
psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
November 16, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
-
psnet.ahrq.gov/issue/black-or-other-doctors-may-be-relying-race-make-decisions-about-your-health
September 15, 2021 - August 19, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
-
effectivehealthcare.ahrq.gov/sites/default/files/pregnancy-horizon-scan-high-impact-1412.pdf
December 01, 2014 - AHRQ did not directly
participate in horizon scanning, assessing the leads for topics, or providing … Since that implementation, review of more than 18,000 leads about potential topics has resulted in … in the past 12–15 months), even
fewer topics have met criteria for tracking because so few of the leads
-
psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Anything
that leads to decreased stooling will tend to increase this enterohepatic circulation; most … This leads to unnecessary separation of mother
and infant and extra costs. … This typically leads to a gradually worsening anemia, rather than a stable hemoglobin for 10 days followed
-
psnet.ahrq.gov/node/49748/psn-pdf
December 01, 2015 - However, controlled clinical studies have shown that spironolactone is far superior—its
use leads to … Many of these patients have elevated circulating
aldosterone concentrations, which leads to avid salt … The vasodilatation that occurs in the splanchnic
bed leads to a lowering of mean arterial pressure and
-
psnet.ahrq.gov/issue/not-what-doctor-ordered
November 23, 2016 - November 4, 2015
Parkland knee surgery done by doctor in training leads to amputation
-
psnet.ahrq.gov/issue/doctors-age-worries-about-their-ability-grow
December 23, 2012 - November 4, 2020
Fear of Covid-19 leads other patients to decline critical treatment.
-
www.uspreventiveservicestaskforce.org/uspstf/methods-and-processes/uspstf-analytic-framework-child-and-adolescent-health-topics
October 01, 2017 - A curved arrow leads to adverse effects of the action.
-
psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-trigger-dangers
June 29, 2016 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/safeguarding-storage-drug-products
December 15, 2010 - May 7, 2018
Misprogramming PCA concentration leads to dosing errors.
-
psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
February 06, 2008 - February 6, 2008
WebM&M Cases
Lapse in Antibiotics Leads