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psnet.ahrq.gov/issue/web-application-involve-patients-medication-reconciliation-process-user-centered-usability
August 18, 2021 - Download Citation
Related Resources From the Same Author(s)
Optimizing Therapy … changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy
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psnet.ahrq.gov/issue/evaluating-patient-safety-learning-laboratory-create-interdisciplinary-ecosystem-health-care
December 21, 2022 - Related Resources From the Same Author(s)
Lessons learned in implementing a chronic opioid therapy … October 27, 2021
Occupational therapy utilization in veterans with dementia: a retrospective
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psnet.ahrq.gov/issue/communication-interdisciplinary-teams-exploring-closed-loop-communication-during-situ-trauma
July 19, 2023 - July 19, 2023
Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid … 21, 2021
Design and implementation of a point-of-care computerized system for drug therapy
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psnet.ahrq.gov/issue/electronic-tools-support-medication-reconciliation-systematic-review
August 18, 2021 - Download Citation
Related Resources From the Same Author(s)
Optimizing Therapy … changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy
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psnet.ahrq.gov/issue/defining-minimum-necessary-anticoagulation-related-communication-discharge-consensus-care
March 04, 2020 - Author(s)
Reduce the likelihood of patient harm associated with the use of anticoagulant therapy … Elements of Performance
March 4, 2020
Delivery of optimized inpatient anticoagulation therapy
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psnet.ahrq.gov/issue/do-hospitals-provide-lower-quality-care-weekends
January 12, 2022 - to the hospital on a weekend have a higher risk of mortality from conditions requiring emergency treatment … AMI) and found that patients admitted on weekends were significantly less likely to undergo invasive treatments … 14, 2018
Patient outcomes in dose reduction or discontinuation of long-term opioid therapy … June 28, 2010
The safety of warfarin therapy in the nursing home setting.
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psnet.ahrq.gov/issue/impact-independent-chemotherapy-prescribing-advanced-practice-providers-patient-safety-and
November 16, 2022 - the randomized AMBORA trial to clinical practice: comparison of medication errors in oral antitumor therapy … April 10, 2024
Uncovering the risks of anticancer therapy through incident report … 2023
Association of polypharmacy and potential drug-drug interactions with adverse treatment
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - earlier CT scan.
7
Case Details (4)
• The neurosurgeon recommended continuing dual antiplatelet therapy … in about 3 weeks to coordinate open gastrostomy tube revision after
discontinuation of antiplatelet therapy … the patient was seen by the
neurosurgeon, who now recommended a 3-month course of dual
antiplatelet therapy … multidisciplinary care coordination with
evolving care plans for management of dual antiplatelet therapy … especially in this case where the PEG
was less than a month old.
– Even without dual antiplatelet therapy
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - safety has been historically focused on dispensing, pharmacists' roles have expanded as medication therapy … patients are using medications can result in suggestions for changes in medication, dosing, or additional therapies … medications is causing an adverse effect; simplify a patient's medication regimen; identify gaps in reaching treatment … Pharmacist may detect dangerously low or high blood pressure and recommend changes in medication therapy … January 26, 2022
Therapeutic duplication on the general surgical wards.
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - All of these factors can result in under-treatment of pain in this patient population.(
5)
When evaluating … This information would be
essential in assessing response to therapy. … He was transferred to the intensive care unit for ongoing monitoring and treatment with naloxone. … Trends in long-term opioid therapy for chronic non-cancer
pain. … Pharmacologic treatment of cancer pain. N Engl J Med. 1996;335:1124-1132. [go to PubMed]
10.
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - was notable for having had an aortic valve replaced with a titanium valve and chronic management at a therapeutic … the emergency department (ED), only that she was chronically anticoagulated using warfarin “with a therapeutic … patient with acute mechanical valve thrombosis, with or without arterial thromboembolism, intravenous therapeutic … Without administering such a bolus, it may take 12-24 hours to reach a therapeutic heparin level. … Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of
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psnet.ahrq.gov/node/49838/psn-pdf
August 01, 2018 - shared decision-making, and symptom management in
the process of the withdrawal of life-sustaining treatments … Withdrawal of life support is a common practice in the ICU, and removing life-saving therapies requires … Checklists have
improved clinical practice in the ICU setting, including withdrawal of life-saving therapies … Preventing errors during the complex process of withdrawing life-saving therapies requires structured … Medical care inconsistent with patients'
treatment goals: association with 1-year Medicare resource
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psnet.ahrq.gov/node/36356/psn-pdf
June 16, 2019 - successes with
read backs, and reports on errors involving non-formulary medications and vincristine therapy
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psnet.ahrq.gov/node/35423/psn-pdf
June 16, 2019 - The primary focus of this segment is safety issues associated with the diabetic therapy Symlin.
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - subsided, and she ultimately was discharged home with IV caspofungin to finish her course
of antifungal therapy … She was discharged home with a PICC line for prolonged IV
caspofungin therapy (a suboptimal antifungal … voriconazole as first-line
therapy.(2) Although posaconazole has excellent in vitro activity against … successful outcomes for invasive Aspergillus, posaconazole should be reserved as a
second- or third-line therapy … Therapy with posaconazole suspension is
associated with subtherapeutic serum concentrations compared
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psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - many days and had Staphylococcus aureus in her bloodstream for more than a week despite antibiotic 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 … at Transfer
May 1, 2012
WebM&M Cases
More Treatment—Better
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psnet.ahrq.gov/node/36000/psn-pdf
June 16, 2019 - ismp-medication-error-report-analysis-5
This monthly selection of medication error reports discusses a mistake with chelation therapy
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psnet.ahrq.gov/node/40298/psn-pdf
May 13, 2019 - safety issues and describes recommendations developed at a
conference to reduce errors in radiation therapy
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psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
October 31, 2018 - Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve … perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies … Resources
Cognitive biases and moral characteristics of healthcare workers and their treatment
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - Trends in long-term opioid therapy for chronic non-cancer pain. … Prevalence and characteristics of hospitalized adults on chronic opioid therapy. … Understanding the pain may allow optimal pharmacologic treatment
Inflammatory pain is optimally treated … Pharmacologic treatment of cancer pain. … He was transferred to the ICU for ongoing monitoring and treatment with naloxone.