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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - The patient failed her swallow evaluation by speech therapy; therefore, a
nasogastric (NG) tube was
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - anticoagulants are monitored daily to assure no adverse events are occurring as a result of their medication therapy
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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/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - widespread use of screening mammography and the introduction of more sophisticated cancer-specific therapies … Doctors Company-CRICO study cited above, patients’ failure to complete recommended appointments or treatments … Navigating risks in breast cancer diagnosis and treatment. … www.rmf.harvard.edu/Clinician-Resources/Article/2015/Navigating-Risks-in-Breast-Cancer-Diagnosis-and-Treatment … , 2023
WebM&M Cases
Sepsis Resulting from Delays in Treatment
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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/837748/psn-pdf
August 05, 2022 - Also, an individualized diabetes care
plan and education on the appropriate use of insulin therapy at … at-risk patients and there is emerging evidence that supports multidisciplinary interventions
including treatment … An on-treatment analysis of the MARQUIS study: interventions
to improve inpatient medication reconciliation
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - Blood cultures were positive for E. coli, and appropriate antibiotic therapy was initiated. … Phone Call
March 1, 2012
WebM&M Cases
More Treatment—Better … Self-Administered Medications
July 1, 2011
WebM&M Cases
Treatment
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - He was diagnosed with post-concussive syndrome; no specific investigations or treatments were recommended … data have largely been limited to case series of elderly patients on antiplatelet or anticoagulation therapy … In this scenario, a false negative CT interpretation would result in a treatment plan that does not include
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - He was diagnosed with Pneumocystis jiroveci pneumonia (PCP) and started on appropriate antibiotic therapy … The patient continued to receive treatment for PCP and was slowly improving.
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - The examples they provide are radiation therapy or blood
transfusions. … For example,
when managing an airway emergency, there is risk in any treatment you might try but there
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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
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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