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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - discussing Artistotle, once wrote, "We do not act rightly because we have virtue or excellence, but we rather … from the patient perspective.( 10 ) However, in other studies, immersive experiences performed better than
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psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
May 27, 2020 - helpful in this Case because the resuscitation event experienced by the team occurred while in a hallway rather … than in a clinical area such as the surgical suite.
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - training and education on the
reporting process, and demonstrate the importance of learning from errors rather … than punishing those who
make them.
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - Rather than admitting guilt or taking sole responsibility for the conflict, an apology can convey a desire
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - patient receiving a single, full day's dose of metoprolol as the immediate-release formulation (tartrate) rather … than the intended extended-release formulation (succinate).
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - The nurse informed him that the patient had developed a junctional rhythm with a heart rate less than … been given 100 mg of metoprolol XL and 180 mg of diltiazem CR by the hospital admitting physician, rather … than the 50 mg of metoprolol XL and no diltiazem intended by her outpatient cardiologist. … flag to medication and problem lists indicating that the patient has been seen in clinic more recently than … of clinical information, it is important not to abandon the safety practices used in the past, but rather
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - Fang, MD, MPH
Venous thromboembolism (VTE) is a common cardiovascular condition that affects more than … saphenous vein), not a deep vein, and placing an inferior vena cava (IVC) filter probably had more risks than … In addition, 13% of patients without an indication for dose reduction received lower-than-standard doses … Don't treat provoked VTE for longer than 3 months. … Don't treat provoked VTE for longer than 3 months
6.
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - However, what constitutes a community-based pharmacy is much broader than the traditional retail setting … The modern concept of medication safety is much broader in scope than the “five rights” and the focus … technologies, policies and procedures, and other systems factors support the outcomes of the various rights, rather … than focusing solely on completion of an oversimplified checklist. … The important thing to recognize is that community pharmacists do so much more than dispense medication
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - data, let's say that we saw something like untreated hypoxia, an oxygen saturation reading of less than … Benchmarking with agencies who are in rural settings may look a little bit different than agencies who … It’s not the end-all be-all, but certainly easier than digging through a stack of 100,000 paper records … safety in the prehospital setting suggests that safety surveillance systems have evolved with time rather … than by design. 1 Safety events in the prehospital setting are sometimes identified through review
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - safety in the prehospital setting suggests that safety surveillance systems have evolved with time rather … than by design. 1 Safety events in the prehospital setting are sometimes identified through review … An example of a clinical trigger in the prehospital setting might be oxygen saturation of less than 94% … was wide variability. 1 Record reviews using trigger tools may portray event rates more accurately than … Benchmarking with agencies who are in rural settings may look a little bit different than agencies who
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Rather, immunoglobulin E (IgE)-
mediated hypersensitivity develops to a subset of the over 200 polypeptides … The fact that such
materials are still being purchased may reflect historical practices rather than
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - Between 1999 and 2018, more than 232,000 individuals in the United States died because of an overdose … EHR adoption rates have been slower, and lower, than in physician practices. 9 Further, many dental … EHR platforms operate as practice management software, rather than as a comprehensive EHR seen in other … /www.cdc.gov/opioids/data/index.html#:~:text=Overdose%20deaths%20involving%20opioids%2C%20including,than
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - This affects more than 100,000 house staff in the United States ( 3 ) and 32,000 in Europe ( 4 ) and … intern in the ICU made significant errors, ones that did not seem to stem from inadequate knowledge but rather
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - At 5:00pm, the ICU nurse mistakenly selected a
jug of dialysis liquid rather than a polyethylene glycol
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - While that sounds kind of squishy, I can tell you that, after literally more than a million submissions … Rather, we often see that leaders feel like it's necessary to throw somebody to the wolves to show that
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Hamilton Depression Inventory, PHQ-
9) can help to attribute mood symptoms to depressive disorder, rather … than to the associated
borderline personality disorder.
17
Diagnostic challenges after attempted
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - training and education on the reporting process, and demonstrate the importance of learning from errors rather … than punishing those who make them.
-
psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Staff focused on medications to manage the patient's behavior, rather than on treating
contributing
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - At 5:00pm, the ICU nurse mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - The metabolic panel was normal except for borderline elevation of serum creatinine, higher than his baseline … “High-risk” abdominal pain is characterized by clinical features including age greater than 65 years, … while also improving resource utilization and decreasing costs to the health system. 23 In this case, rather … than discharging the patient with a questionable diagnosis and unresolved pain, the clinician could