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psnet.ahrq.gov/issue/computerized-clinical-decision-support-during-medication-ordering-long-term-care-residents
February 11, 2009 - WebM&M Cases
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage … Impact of health information technology on detection of potential adverse drug events at the ordering stage
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psnet.ahrq.gov/node/867441/psn-pdf
January 08, 2025 - Consumer involvement in the design and development of
medication safety interventions or services in primary
care: a scoping review.
January 8, 2025
DelDot M, Lau E, Rayner N, et al. Consumer involvement in the design and development of medication
safety interventions or services in primary care: a scoping review.…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage … renal disease
4
Case Details (1)
• A 38-year-old man with end-stage renal disease (ESRD) on chronic … , and rehabilitation was delayed.
6
OVERDOSE OF GABAPENTIN AND OXYCODONE
IN A PATIENT WITH END-STAGE … • For example, drug dosing alerts (for any mention of CKD) may fire for
patients with CKD Stage 1 … Pharmacotherapeutic considerations for chronic pain in chronic kidney and end-stage renal disease.
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psnet.ahrq.gov/node/866314/psn-pdf
July 17, 2024 - This review analyzed the evidence on specimen errors during the pre-analytical stage.
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psnet.ahrq.gov/issue/effect-staged-emergency-department-specific-rapid-response-system-reporting-clinical
March 24, 2021 - Study
The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration.
Citation Text:
Considine J, Rawet J, Currey J. The effect of a staged, emergency department specific rapid response system on reporting of clinical deterioration. Aus…
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psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Leading change: why transformation efforts fail.
April 7, 2010
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process,
as well a…
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psnet.ahrq.gov/node/73530/psn-pdf
July 28, 2021 - Most errors occurred during the prescribing stage
and were the result of interrelated causes such as
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psnet.ahrq.gov/node/837677/psn-pdf
July 13, 2022 - why-test-results-are-still-getting-lost-follow-qualitative-study-implementation-gaps
https://psnet.ahrq.gov/issue/inaccuracies-assignment-clinical-stage-localized-prostate-cancer
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - – Stage II progresses to include stabbing or shooting radicular pain,
nuchal rigidity/neck stiffness … – Stage III includes the development of sensory abnormalities, motor
weakness, and bowel or bladder … – Stage IV is defined by paralysis. … • SEA does not necessarily always progress in this manner
– Not all symptoms may be present at each stage … – Advanced neurologic deficits may include paraparesis and quadriparesis,
but these are late-stage
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psnet.ahrq.gov/node/46397/psn-pdf
August 30, 2017 - psnet.ahrq.gov/issue/mistakes-we-make-dialysis
https://psnet.ahrq.gov/issue/ahrq-safety-program-end-stage-renal-disease-facilities-toolkit
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psnet.ahrq.gov/node/39304/psn-pdf
February 17, 2010 - that harmful errors involving antidepressants most commonly
occurred at the medication administration stage
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - below)
Symptoms may occur over hours to days and patients may present with sepsis or septic shock
15
Stage … 1 (early) Stage 2 (intermediate) Stage 3 (late)
Warm to palpation Blister or bullae formation (serous … constant review of a patient are the only ways to reliably detect necrotizing fasciitis at an early stage
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psnet.ahrq.gov/node/836829/psn-pdf
March 30, 2022 - /patient-safety-challenges-low-income-and-middle-income-countries
https://psnet.ahrq.gov/issue/what-stage-are-low-income-and-middle-income-countries-lmics-patient-safety-curriculum
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psnet.ahrq.gov/issue/undergraduate-baccalaureate-nursing-students-self-reported-confidence-learning-about-patient
February 04, 2015 - January 30, 2019
What stage are low-income and middle-income countries (LMICs) at with … A two-stage cross-sectional study.
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psnet.ahrq.gov/issue/self-reported-patient-safety-competence-among-canadian-medical-students-and-postgraduate
December 04, 2015 - January 30, 2019
What stage are low-income and middle-income countries (LMICs) at with … A two-stage cross-sectional study.
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psnet.ahrq.gov/issue/bridging-leadership-roles-quality-and-patient-safety-experience-6-us-academic-medical-centers
September 04, 2016 - December 12, 2018
What stage are low-income and middle-income countries (LMICs) at with … A two-stage cross-sectional study.
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psnet.ahrq.gov/node/866692/psn-pdf
September 11, 2024 - Nearly one-third of errors were wrong
dose and occurred in the prescribing stage.
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psnet.ahrq.gov/node/37755/psn-pdf
April 14, 2011 - Such systems may serve as a method to prevent medication errors,
particularly at the prescribing stage
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psnet.ahrq.gov/node/43354/psn-pdf
July 16, 2014 - weaving-healthcare-tapestry-safety-and-communication
https://psnet.ahrq.gov/issue/morning-briefing-setting-stage-clinically-and-operationally-good-day
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psnet.ahrq.gov/node/848358/psn-pdf
May 03, 2023 - contributed to diagnostic error in 61% of claims, the majority in outpatient care,
and 92% at the testing stage