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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Even with the truncated information presented in this case, I believe that the therapeutic impasse and … A clinician hearing such an admission should wonder whether this was “a cry for help” to test the therapeutic … alliance and may not be a suitable candidate for therapy. … Removing the gun before initiating treatment might have allowed the therapeutic alliance to develop. … Inevitably, this approach ends in futility for the therapist, dooming the therapy.
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psnet.ahrq.gov/node/39434/psn-pdf
April 07, 2010 - offers information to help patients understand both safety issues and risks involved in
radiation therapy
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psnet.ahrq.gov/node/40685/psn-pdf
August 10, 2011 - reveals expert opinion from the American Society of Radiation Oncology on intensity-
modulated radiation therapy
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psnet.ahrq.gov/issue/potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-drug-events
April 22, 2015 - April 22, 2015
Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid … changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy … 2010
Consistency between coded poison center data and fatality abstract narratives for therapeutic
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - One study
of intrahospital transport of non-ICU patients found that oxygen therapy was frequently interrupted … variability among hospitals in the responsibilities of
respiratory care practitioners and nurses for oxygen therapy … therapists are best prepared to provide education and be involved in improving care related to
oxygen therapy … Interruption of oxygen therapy during intrahospital transport of non-
ICU patients: elimination of a … Who ensures that therapies (eg, oxygen, infusions, etc.) are maintained during transport?
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psnet.ahrq.gov/node/41560/psn-pdf
August 01, 2012 - improving-medication-safety-high-risk-medicare-beneficiaries-toolkit
This toolkit provides resources to help develop a medication therapy
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psnet.ahrq.gov/node/36267/psn-pdf
October 21, 2010 - antiretroviral-medication-errors-among-hospitalized-patients-hiv-infection
The authors found that HIV-infected patients receiving highly active antiretroviral therapy
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psnet.ahrq.gov/node/37509/psn-pdf
January 30, 2008 - hidden-danger-obvious-opportunity-error-and-risk-management-cancer
This commentary provides context on risks, errors, and safety in cancer treatment … a recent
analysis by the Chief Medical Officer for the United Kingdom regarding error in radiation therapy
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psnet.ahrq.gov/node/40587/psn-pdf
January 22, 2017 - recommendations-action
This commentary describes strategies to improve safety in radiation oncology therapy
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psnet.ahrq.gov/node/45583/psn-pdf
January 18, 2017 - project, this report describes how standardization can improve reliability
and safety of intravenous therapy
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - patient care, move toward a culture that is
collaborative and supports questions pertaining to drug therapy … environment that provides the time practitioners need to think through their patients'
diagnoses and treatments … and match the appropriateness of drug therapy with the patient (i.e., right
drug for diagnosis, laboratory … Patient Education:
Encourage patients to question their drug therapy when they are uncertain. … Educate patients about all aspects of their drug therapy, including the drug name (generic and
trade
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - The neurosurgeon recommended continuing dual antiplatelet therapy for 2 months after carotid stent placement … 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 the dual antiplatelet therapy … Timing of discontinuation of anti-platelet therapy after invasive procedures is based on an individualized
-
psnet.ahrq.gov/issue/high-alert-medication-learning-guides-consumers
April 30, 2019 - December 15, 2021
2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy … May 24, 2023
WebM&M Cases
Duplicate Therapies in Retail
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - 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 … A randomized controlled
trial demonstrated that a dedicated IV therapy team of registered nurses specially … Prevention of peripheral venous catheter complications
with an intravenous therapy team: a randomized
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - with these other important end-organ injuries, delirium is a clinical event for which prevention and
treatment … Patients received therapy for 87% of study days, and experienced an average of 2 fewer days of
delirium … In addition to delirium prevention, early treatment needs further study, such as cognitive therapy while … The ABCDE model is an initial framework on which new prevention and treatment strategies can
be added … Recognition of delirium must prompt consideration
and treatment of underlying causes.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
February 01, 2011 - *
Case: One Toxic Drug (2)
Prior to therapy, the physician did not refer the patient for a liver … After 6 weeks of therapy, the HCV viral load was unchanged, and the patient exhibited pancytopenia. … After 9 months of treatment, a viral load was repeated and was again found to be more than 2,000,000 … The improper care included: (i) no liver biopsy to see if the patient met the criteria for treatment; … (ii) no genotype performed to help guide length of therapy; (iii) no baseline labs to see if the patient
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psnet.ahrq.gov/node/39276/psn-pdf
March 09, 2011 - this news feature investigates patient deaths and injuries following
mistakes related to radiation treatment … The journalists discuss the number of radiation therapy errors in
New York and reveal that state law
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psnet.ahrq.gov/node/36388/psn-pdf
June 12, 2013 - using-patient-safety-science-explore-strategies-improving-safety-intravenous-
medication
The author describes types of errors that occur in intravenous (IV) medication therapy
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - monitoring parameters for DOACs such as the International Normalized Ratio (INR) which reflects the therapeutic … molecular weight heparinoid medication to “bridge” the gap in anticoagulation until the DOAC regains therapeutic … making it difficult for providers to keep up with the most current evidence-based and FDA-approved drug treatments … Examples of specific indications include: VTE treatment vs atrial fibrillation treatment, using warfarin … vs DOACs, normal vs. impaired renal function, weight adjustment and initial treatment vs. chronic treatment
-
psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - The delay in appropriate treatment of sepsis
with continued antibiotic therapy on admission resulted … for antibiotics were in place, we
found only 3 instances in which the expiration of an antibiotic therapy … Take-Home Points
Early identification and treatment improves outcomes in patients with sepsis. … Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Collaborative Group. … Early goal-
directed therapy in the treatment of severe sepsis and septic shock.