-
psnet.ahrq.gov/issue/medical-devices-and-patient-safety
February 22, 2012 - February 22, 2012
Drug shortages: effect on parenteral nutrition therapy. … July 22, 2020
Occupational therapy utilization in veterans with dementia: a retrospective
-
psnet.ahrq.gov/node/867646/psn-pdf
January 01, 2022 - Initiative (OSI) toolkit
includes materials and presentations to support clinical decision-making in opioid therapy
-
psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - During
this gap in therapy, the patient experienced recurrence of paranoia and required readmission … FDA) has identified certain medications that need special attention to
ensure that the benefits of therapy … care team, including the patient, about particular strategies that can reduce the likelihood of the
therapy … an adverse drug event, not from the risks that were managed through
the REMS, but from missing his treatment … clozapine REMS, inpatient dose modifications
no longer require REMS-authorized providers to adjust therapy
-
psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - • Providers need to understand contraindications to insulin pump therapy and
discuss contraindications … • Admitting provider should decide whether to continue insulin pump therapy
in collaboration with … • Daily communication about the goals of therapy can reduce
patients’ and caregivers’ resistance … Diabetes technology & therapeutics 2019;21:66-72.
6. Munt R, Hutton A. … Diabetes technology & therapeutics 2017;19:363-
9.
17. American Diabetes A. 15.
-
psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - Whether the administration of thrombolytic therapy to a “stroke mimic” equates to a medical
error is … guidelines recommend
thrombolysis to avoid missing the therapeutic window even when a “stroke mimic … While diagnostic uncertainty is not unique to stroke, the time-dependent nature of AIS therapy—amidst … window is narrow, if withholding treatment would cause harm, if the
risk of treatment is acceptably … have
limited access to the patient.2,21
Biases can infiltrate multiple phases of the diagnostic and therapeutic
-
psnet.ahrq.gov/node/50648/psn-pdf
November 06, 2019 - faced-drug-shortfall-doctors-scramble-treat-children-cancer
Drug shortages create potential complexities in drug therapy
-
psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
May 22, 2017 - Physical dependence itself is a harm because it leads to self-perpetuating therapies for drugs that by … They're less happy to pay for physiotherapy, occupational therapy, or cognitive behavioral therapy for … There is a role for the use of opioids in the treatment of chronic pain. … 4 ) Besides affecting quality of life, management of these adverse events often involves additional therapeutics … to the opioid epidemic, including the redesign of payment policies to promote the use of nonopioid treatments
-
psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - 4 ) Besides affecting quality of life, management of these adverse events often involves additional therapeutics … to the opioid epidemic, including the redesign of payment policies to promote the use of nonopioid treatments … Physical dependence itself is a harm because it leads to self-perpetuating therapies for drugs that by … They're less happy to pay for physiotherapy, occupational therapy, or cognitive behavioral therapy for … Same Author(s)
Effects of state opioid prescribing laws on use of opioid and other pain treatments
-
psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Despite this therapy, her
symptoms persisted. She was then prescribed azithromycin. … If antibiotics were not warranted, management should have focused on
symptomatic therapy, including … The patient was prescribed Augmentin (amoxicillin-clavulanate) as initial therapy. … of amoxicillin along with
symptomatic therapies. … She was started on high-dose
immunosuppressive therapy with steroids.
-
psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - 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 use
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - • Whether the administration of thrombolytic therapy to a “stroke mimic” equates to
a medical error … guidelines recommend thrombolysis to avoid missing the
therapeutic window even when a “stroke mimic … Heart Association for Comprehensive Stroke Center certification is
administration of thrombolytic therapy … window is narrow, if withholding treatment would cause
harm, if the risk of treatment is acceptably … .2,21
32
Heuristics and Biases (2)
• Biases can infiltrate multiple phases of the diagnostic and therapeutic
-
psnet.ahrq.gov/node/867449/psn-pdf
March 13, 2025 - Body. 2024-2025
https://psnet.ahrq.gov/issue/medication-related-harm
Omitted or delayed medication therapy
-
psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - inpatient and outpatient settings regarding changes in other
medications, clinical status, and warfarin treatment … Meta-analysis: antithrombotic therapy to prevent stroke in patients who
have nonvalvular atrial fibrillation … Risk of thromboembolism with short-term interruption of warfarin
therapy. … Warfarin monitoring in ambulatory older individuals
receiving antimicrobial therapy. … Randomized controlled trial of supervised patient self-testing of warfarin
therapy using an internet-based
-
psnet.ahrq.gov/node/865598/psn-pdf
April 17, 2024 - psnet.ahrq.gov/issue/guardians-grafts-reducing-medication-errors-transplant-recipients
Safe medication therapy
-
psnet.ahrq.gov/issue/shift-coupon-innovative-method-monitor-adverse-events
June 25, 2010 - July 21, 2010
Occupational therapy utilization in veterans with dementia: a retrospective … April 15, 2016
Medication errors with antituberculosis therapy in an inpatient, academic
-
psnet.ahrq.gov/issue/error-avoidance-recommendations-tubing-misconnections-when-using-luer-tip-connectors
November 21, 2018 - Related Resources
Quality and Safety Considerations in Intensity Modulated Radiation Therapy … June 16, 2019
ASPEN Safe Practices for Enteral Nutrition Therapy.
-
psnet.ahrq.gov/issue/recognizing-ordinary-extraordinary-insight-way-we-work-improve-patient-safety-outcomes
December 12, 2012 - March 2, 2010
Increasing patient safety and efficiency in transfusion therapy using formal … November 14, 2018
Making an infusion error: the second victims of infusion therapy-related
-
psnet.ahrq.gov/issue/effectiveness-computerized-system-intravenous-heparin-administration-using-information
February 27, 2009 - February 27, 2009
Impact of pharmacist-provided medication therapy management on healthcare … December 30, 2014
Relationship of incorrect dosing of fibrinolytic therapy and clinical
-
psnet.ahrq.gov/issue/medication-errors-routines-and-differences-between-perioperative-and-non-perioperative-nurses
June 27, 2018 - June 27, 2018
Making an infusion error: the second victims of infusion therapy-related … July 31, 2013
ASPEN Safe Practices for Enteral Nutrition Therapy.
-
psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. … Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023. … ARNI, specifically sacubitril
and valsartan) due to worsening symptoms despite standard multi-drug therapy … therapy errors that occurred in both cases reflect fragmented care with lapses in coordination
and … Duplicate therapy errors have the potential to be serious and may result in adverse drug events (ADE)