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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital … Surgery was canceled, and she was placed on anticoagulation therapy and managed conservatively for appendicitis … Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; American College of Chest Physicians Antithrombotic Therapy … Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - The interval between symptom onset and clinical assessment will determine whether acute reperfusion
therapy … thrombin time or ecarin clotting time; laboratory assays are often not processed
quickly enough to make therapeutic … have a database or registry capable of tracking the number and type of stroke patients seen, their
treatments … , timelines for receiving treatments, and measurement of clinical outcomes.(15) A system should
be in … these recommendations it is expected that patients will achieve more
accurate diagnoses, more timely therapies
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psnet.ahrq.gov/node/47223/psn-pdf
August 14, 2018 - vital-signs-trends-emergency-department-visits-suspected-opioid-overdoses-united-states-july
https://psnet.ahrq.gov/issue/improving-adherence-long-term-opioid-therapy-guidelines-reduce-opioid-misuse-primary-care
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psnet.ahrq.gov/node/44257/psn-pdf
November 06, 2015 - systems-approach-evaluating-ionizing-radiation-six-focus-areas-improve-
quality-efficiency-and
Radiation therapy
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psnet.ahrq.gov/node/37310/psn-pdf
January 05, 2012 - time-out
strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - Phlebitis (inflammation of the vein where the IV is placed) complicates IV therapy in 2.3%–60% of cases … Fortunately, after aggressive therapy and a prolonged course, the patient eventually recovered. … The extra cost of MRI, imaging-guided aspiration of epidural abscesses, 6-week IV antimicrobial therapy … Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized … Misplaced PEG
August 1, 2012
WebM&M Cases
More Treatment—Better
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psnet.ahrq.gov/node/35471/psn-pdf
September 21, 2009 - With ongoing advances in such therapy and
a growing shift to outpatient treatment in infusion clinics … prevention strategies that came from their local findings and how the
complexity of outpatient oncology treatment
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - The patient described in this case was receiving parenteral nutrition (PN), a life-sustaining therapy … Such therapy is used in patients of all ages and across care settings (from intensive care units to the … The PN-use process refers to the numerous steps in providing PN therapy, including prescribing, order … Nutrition Support Services Hospital of the University of Pennsylvania Professor, Pharmacology & Therapeutics … Related Resources From the Same Author(s)
ASPEN Safe Practices for Enteral Nutrition Therapy
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - many days and had Staphylococcus aureus in her
bloodstream for more than a week despite antibiotic therapy … bacterial contamination of blood has been a well-recognized and documented problem in
transfusion therapy … bacterial contamination of blood products the third leading reported cause of death from transfusion
therapy … Clinicians and nurses caring for patients undergoing platelet transfusion therapy should monitor
patients … suggest the possibility of a septic reaction and be prepared to
discontinue the transfusion and begin treatment
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psnet.ahrq.gov/issue/diagnostic-error-result-drug-laboratory-test-interactions
November 21, 2018 - test interactions can lead to misinterpretation of results, misdiagnosis, and unneeded tests or therapies … March 9, 2022
ASPEN Safe Practices for Enteral Nutrition Therapy.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.458_slideshow.ppt
October 01, 2018 - Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant … Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis … Using procalcitonin to guide antibiotic therapy. … have an infection had higher mortality rates, which may have been related to delays in appropriate therapy … predictive value and may contribute to alert fatigue and the administration of inappropriate sepsis therapies
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psnet.ahrq.gov/issue/diseases-medical-progress
June 27, 2018 - that the history of medicine provides numerous examples of how emerging illnesses develop from sound therapeutic … The author discusses more than 40 distinct entities that resulted from new and existing medication therapies … fascinating historical perspective, one that not only raises concern over all currently available novel therapies
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psnet.ahrq.gov/issue/intravenous-chemotherapy-preparation-errors-patient-safety-risks-identified-pan-canadian
March 18, 2011 - June 13, 2018
Improving shared situation awareness for high-risk therapies in hospitalized … The use of human factors methods to identify and mitigate safety issues in radiation therapy
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - that they would be more likely to override a DNR order when an arrest was caused by a complication of treatment … families want to be involved in decision making, establish goals based on the prognosis, and implement therapies … eg, if after several days the patient was still on mechanical ventilation and receiving vasopressor therapy … patients understand the potential course of events and prognosis, it is easier to establish the goals of therapy … Overriding a patient′s refusal of treatment after an iatrogenic complication.
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - instance in which a resident's misread film results in a
patient being sent home without appropriate treatment … or in a patient receiving improper surgery or other
therapies. … The patient did not have
bleeding complications from the thrombolytic therapy. … A safeguard such as this (if extended to the use of thrombolytic therapy) may have
prevented the error … more junior reviewers, or those
whose interpretations could prompt procedures or life-threatening therapies
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - endoscopic procedure and, after the procedure, wrote orders for the
patient to receive all of the previous treatments … These lists could
prompt prescribers to reorder medication therapies that were discontinued for procedures … case presented in this commentary, a 25-year-old woman experienced elevated sodium levels after
DDAVP therapy … if the intern further clarified the order to indicate what should
be done with the patient's DDAVP therapy … The intern could have indicated to restart therapy
the next day or based on the patient's sodium levels
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psnet.ahrq.gov/issue/impact-electronic-communication-medication-discontinuation-cancelrx-medication-safety-pilot
December 07, 2022 - September 20, 2023
WebM&M Cases
Duplicate Therapies in … May 5, 2021
Analysis of medication therapy discontinuation orders in new electronic prescriptions
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - or
discontinuation of a critical drug, giving the end users time to find alternative resources or therapies … 1516 directors of
pharmacy, and they reported that out of 171 responses, 70.8% reported a delay in treatment … , 48.5%
reported patients received suboptimal therapies, 15.8% reported a treatment failure, and 1.2% … regarding
shortages along with frequent in-service education activities (when alterations from standard treatment … Drug shortages: effect on parenteral nutrition therapy. Nutr Clin
Pract. 2018;33:53-61.
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Although the case above highlights the potential dangers of therapy duplication, it also illustrates … the medication reconciliation process identified the cause of the admission and resulted in prompt treatment … of the patient (in this case, discontinuation of duplicate therapies) as opposed to reducing future … as drug information from a pharmacist that included the purpose and side effects of the prescribed treatment … access to the complete medical record and prescription fill history could have identified the duplicate therapy
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psnet.ahrq.gov/issue/uptake-pharmacist-recommendations-patients-after-discharge-implementation-study-patient
December 14, 2016 - 19, 2022
Patient outcomes in dose reduction or discontinuation of long-term opioid therapy … September 13, 2023
WebM&M Cases
Duplicate Therapies in