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psnet.ahrq.gov/issue/avoidable-death-three-year-old-child-sepsis
August 31, 2016 - outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - and then reusing it for subsequent treatments in the same patient. … Reusing dialyzers lowers the cost of a dialysis treatment and reduces the amount of biomedical waste … per day, or more than 500 treatments per week. … to limit the number of patients initiating therapy at the same time may all reduce the potential for … Characteristics and treatment of patients not reusing dialyzers in reuse units.
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psnet.ahrq.gov/issue/doctors-and-dentists-still-flooding-us-opioid-prescriptions
October 13, 2018 - January 11, 2023
Effects of state opioid prescribing laws on use of opioid and other pain treatments … 30, 2021
Associations between stopping prescriptions for opioids, length of opioid treatment
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psnet.ahrq.gov/issue/so-why-didnt-you-think-baby-was-ill-decision-making-acute-paediatrics
April 10, 2019 - other elements that can degrade the patient assessment required to inform appropriate diagnosis and treatment
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psnet.ahrq.gov/issue/implicit-bias-healthcare-professionals-systematic-review
September 28, 2022 - Biases were detected in provider attitudes, treatment decisions, and diagnosis.
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psnet.ahrq.gov/issue/inappropriate-hospital-admission-risk-factor-subsequent-development-adverse-events-cross
March 09, 2022 - Inappropriate care, such as under- or over-treatment or unnecessary hospitalizations, can place patients
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psnet.ahrq.gov/issue/inappropriate-prescriptions-direct-oral-anticoagulants-doacs-hospitalized-patients-narrative
November 21, 2018 - prescribing of DOACs and how pharmacists and anticoagulant stewardship programs can optimize inpatient DOAC treatment
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - Experiences of safety among patients receiving home dialysis therapies. … With extracorporeal circuits, you are having to do more, even though it's shorter treatments oftentimes … In-center treatments are only three days a week so you have more aggressive fluid removal than if you … After each treatment session, an app will record the treatment, patients can provide comments on the … water and hemodynamics, and then how to adjust the therapy, the limitations of the therapy (for example
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psnet.ahrq.gov/issue/employee-silence-health-care-charting-new-avenues-leadership-and-management
May 04, 2022 - December 12, 2023
Unequal Treatment Revisited: A Workshop Series.
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psnet.ahrq.gov/issue/association-between-professional-burnout-and-engagement-patient-safety-culture-and-outcomes
October 28, 2020 - Safety risks associated with physical interactions between patients and caregivers during treatment
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - diet, exercise, and glucose monitoring should begin at diagnosis for all patients and may be the only therapy … the case presentation, is available only for subcutaneous administration; is indicated for adjunctive therapy … She also complained that her acne had worsened, and she requested treatment for it. … She was prescribed a topical cream for her acne, and her insulin was increased slightly.
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - due to hemolysis, but felt that the patient should be admitted to the hospital for further workup and treatment … have been consistent with hyperkalemia (high potassium levels), but she did not institute immediate treatment … In this case, the hospitalist probably should have instituted treatment for hyperkalemia before the results … the patient had electrocardiographic changes consistent with hyperkalemia and the risk of instituting treatment … WebM&M Cases
Failed Interpretation of Screening Tool: Delayed Treatment
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psnet.ahrq.gov/issue/safe-practice-recommendations-use-copy-forward-nursing-flow-sheets-hospital-settings
May 18, 2022 - July 24, 2017
Predictors of treatment error for children with uncomplicated malaria seen … transition communication: implementation of an electronic medical record-based tool for improved cancer treatment
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - seeking help can lead to self-treatment. … For some physicians, a separate but special concern is self-treatment with addictive drugs. … Thus, there is a need to find new strategies to help physicians obtain optimal treatment. … It is important to ask about self-treatment and self-diagnosis and to discuss the diagnostic and treatment … Ask about self-treatment and self-diagnosis and discourage these practices.
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - leave the facility having been informed of and appreciating the risks of leaving without completing treatment … .( 4 ) Fully competent patients are legally able to discharge themselves without completing treatment … responsibilities while hospitalized, including the need to communicate with staff prior to leaving a treatment … When a patient is mentally able to consent to treatment and is able to fully partner with health care … Competent patients who choose to leave without completing treatment cannot be held against their wishes
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psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-way-patient-safety
April 03, 2019 - error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment
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psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
May 13, 2020 - The complexity of care relationships is viewed as playing a role in how appropriate treatment for patients
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psnet.ahrq.gov/issue/joshuas-story
February 26, 2014 - features an in-depth interview with the father of an infant who died following delayed diagnosis and treatment
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psnet.ahrq.gov/issue/impacts-pharmacist-managed-outpatient-clinic-and-chemotherapy-directed-electronic-order-sets
June 18, 2014 - November 17, 2021
Use of therapeutic outcomes monitoring method for performing of pharmaceutical … impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment … September 28, 2010
Minimising treatment-associated risks in systemic cancer therapy.
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psnet.ahrq.gov/issue/medication-errors-involving-oral-chemotherapy
January 06, 2017 - November 1, 2017
Breast cancer treatment delays by socioeconomic and health care access … events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment