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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - single full-thickness pressure ulcer in one patient can be as much as $70,000; in 2006,
inpatient treatment … points including
severe kyphoscoliosis or other unusual skeletal anomalies, and previous radiation therapy … While treatment of all hip fracture patients with a pressure
redistribution surface is not a new idea
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psnet.ahrq.gov/node/44696/psn-pdf
September 01, 2016 - concept of "number needed to treat" is used to quantify the number of patients who would need to
undergo therapy
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psnet.ahrq.gov/node/36559/psn-pdf
July 14, 2010 - sought to enroll
students in all health professions (medicine, nursing, pharmacy, physical/occupational therapy
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psnet.ahrq.gov/node/41465/psn-pdf
January 31, 2013 - prescriptions written for patients discharged from the ED, in order to prevent errors and to optimize medical
therapy
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psnet.ahrq.gov/node/47295/psn-pdf
September 24, 2018 - The learning
communities focused on patient-centered care, improving medication therapy for distinct
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psnet.ahrq.gov/classics
August 01, 2023 - Information Systems
(50)
Electronic Health Records
(36)
Computer-Assisted Therapy … article describes two experimental studies exploring the impact of gender biases on pain estimation and treatment … Clinical decision support (CDS) systems are intended to support diagnosis and therapeutic processes of … impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment … the intervention group reported considerably fewer medication errors and side effects and increased treatment
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - with warfarin, and a heparin drip was initiated with the plan to bridge her until her INR was in the therapeutic … reporting improves transparency and can empower patients to make better choices about where to seek treatment … Finally, direct harm can occur when caregivers are faced with diagnostic or therapeutic uncertainty, … with antibiotics intended for treatment of pneumonia, or how frequently patient on narcotics are administered … of intramuscular influenza immunization among patients receiving long-term warfarin anticoagulation therapy
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - For Response , birthing facilities must be prepared to administer medications for prevention and treatment … Continued abnormal vital signs should then prompt the health care team to escalate diagnostic and therapeutic … protocols with built-in triggers for objective data provide the infrastructure that enables equitable treatment … updated CMQCC guidelines on obstetric hemorrhage now include tranexamic acid (TXA) as an adjunctive therapy … The Joint Commission. [ Available at ] R 3 Report: Provision of Care, Treatment, and Services standards
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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/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/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/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
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psnet.ahrq.gov/issue/surveillance-medical-device-related-hazards-and-adverse-events-hospitalized-patients
March 11, 2011 - Related Resources
Quality and Safety Considerations in Intensity Modulated Radiation Therapy … June 15, 2022
Improving shared situation awareness for high-risk therapies in hospitalized
-
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