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psnet.ahrq.gov/perspective/safety-retail-pharmacy
May 11, 2016 - October 17, 2012
Medication errors in the ambulatory treatment of pediatric attention
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment
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psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
September 01, 2011 - A theophylline blood level, drawn on admission, was 1.2 mg/L (therapeutic range: 10-20 mg/L). … with 6.6% being near misses and 0.9% resulting in actual patient harm.( 4 ) Medications with a narrow therapeutic … Finally, there was likely no urgent need to achieve a theophylline blood level within the therapeutic … is admitted with a low or high dose (or blood level) of a medication, especially those with a narrow therapeutic … December 30, 2014
WebM&M Cases
Treatment Challenges After
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/qica-healthy-hearts.pdf
June 02, 2025 - Comprehensive,
guideline-based
information on
prevention or chronic
illness treatment
…is not readily
-
psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - The therapeutic window
for many of our interventions is much narrower in these patients. … young people and instead really pay attention to the potential short-term consequences of misjudging
treatment … Medication is such a key part of our
therapeutic efforts. … However, there is a narrower therapeutic window in our frail older patients.
-
psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Results Manager,( 12 ) which offers an electronic method to track results, with options for reminders, treatment
-
psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - Moreover, patients' physical and
emotional symptoms, the direct effects of medication and treatment,
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/099-cusp-guide-why-choose-cusp-approach.docx
October 01, 2024 - safety culture has been associated with reduced patient safety issues, such as infection rates and treatment
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - If patients feel involved in their care, they will be more likely to follow their treatment plans and
-
psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - More
Related Resources
WebM&M Cases
Correct Treatment
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-removal.pptx
April 01, 2022 - sepsis 3 days ago
He required a central venous catheter (CVC) for invasive monitoring and vasopressor therapy … peripherally inserted central catheter (PICC) placement on day 2 for blood draws and IV antibiotic treatment … Program for ICUs: Preventing CLABSI and CAUTI
7
Recommendations for CVC Removal6-9
2016 Infusion Therapy … of current line-related infection
Symptoms of venous occlusion (arm pain, swelling) persist despite therapeutic … Infusion therapy, standards of practice, 2016 update. J Infus Nurs. 2016;39(1S):51-5.
-
psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - She received whole brain radiation treatment, and is currently in remission, but she suffers from severe
-
psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - After several days of aggressive
treatment, the patient was improving and was being managed on the medical-surgical
-
psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - These changes likely represent a response to treatment provided by EMS, such as rest, oxygen, aspirin
-
psnet.ahrq.gov/node/49604/psn-pdf
June 01, 2010 - By that point, the anesthesiologist on call
for the night had arrived, unaware of any of the treatment … Standard guidelines dictate
that systemic anticoagulant therapy or low-molecular-weight heparin thromboprophylaxis
-
psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - characterize everyone who's eligible for care, those who have received specific diagnoses,
tests, and treatment … to identify patients who are at risk for problems
with opioid dependence or complications of opioid therapy
-
psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - 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)
-
psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - During this gap in therapy, the patient experienced recurrence of paranoia and required readmission to … (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
-
www.ahrq.gov/research/publications/pubcomguide/pcguide1a.html
March 01, 2025 - Nonsurgical Treatments for Urinary Incontinence in Women: A Systematic Review Update.
-
psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - Some called for backup airway teams, resulting in delays in treatment.