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psnet.ahrq.gov/issue/serious-adverse-events-pediatric-procedural-sedation-and-after-implementation-pre-sedation
February 12, 2020 - retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated
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psnet.ahrq.gov/issue/emergency-department-volume-and-delayed-diagnosis-serious-pediatric-conditions
September 13, 2023 - This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the
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psnet.ahrq.gov/issue/alcoholism-and-american-healthcare-case-patient-safety-approach
March 30, 2022 - concluded that patients with AUD are frequently undiagnosed and not appropriately referred for treatment or treated
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psnet.ahrq.gov/issue/epidemiology-patterns-care-and-mortality-patients-acute-respiratory-distress-syndrome
August 04, 2021 - observational study found that acute respiratory distress syndrome remains under-recognized and under-treated
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psnet.ahrq.gov/issue/association-hospitalist-years-experience-mortality-hospitalized-medicare-population
May 11, 2022 - physicians in their first year of practice have a slightly higher 30-day mortality risk than those treated
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psnet.ahrq.gov/issue/addressing-adultification-black-pediatric-patients-emergency-department-framework-decrease
October 27, 2021 - as Root Cause ( RRC) framework to identify and reduce adultification (when children are perceived or treated
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psnet.ahrq.gov/issue/parents-understanding-medication-discharge-and-potential-harm-children-medical-complexity
April 22, 2020 - This cross-sectional study of medically complex children treated at one academic hospital in Austria
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psnet.ahrq.gov/node/40236/psn-pdf
March 23, 2012 - A past AHRQ WebM&M
commentary discussed a case where a patient was incorrectly treated based on failure
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psnet.ahrq.gov/node/46709/psn-pdf
December 22, 2018 - observational cohort study of Medicare patients found
no differences in 30-day mortality in those treated
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psnet.ahrq.gov/node/46624/psn-pdf
November 29, 2017 - decision-making should be approached like other adverse
events—examined with root cause analysis and treated
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - patient
biased by experience with past
cases
A patient with crushing chest pain was incorrectly
treated … by subtle cues
and collateral information
A with opioid misuse disorder with abdominal pain was
treated
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - common neurological presentations,
such as migraine headache, can be reliably diagnosed and effectively treated … Clinical outcomes are strongly associated with time to treatment in acute ischemic stroke patients treated … , maximum dose 90 mg).(10) Favorable outcomes at 3 months were achieved
in the 31%–50% of patients treated … Patients treated within 90 minutes of onset achieved
better outcomes than those who were treated between … reduce onset-to-treatment times
and facilitate the best possible outcomes for ischemic stroke patients treated
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - The patient was treated with penicillin in the urgent care clinic. … reporting of STDs is to insure that: (i) Persons who are infected are quickly diagnosed and appropriately treated … to control spread of infection; (ii) Partners are notified, tested, and appropriately treated; (iii) … health departments, determine if a reactive syphilis serology represents a new infection or a previously treated
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Retroperitoneal bleeding is treated by
aggressive volume resuscitation, correction of coagulopathy, … smaller pseudoaneurysms can often be managed conservatively, larger
pseudoaneurysms will usually be treated … Arterial puncture closing devices do not necessarily decrease local vascular complications, and
patients treated … with these devices should undergo the same vigilant monitoring as those treated
with manual compression
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated … and was growing
Listeria monocytogenes, a bacterium that can cause life-threatening infection if not treated … suggest that the gram-positive rod is a true pathogen.(12)
Whether a positive blood culture should be treated … Gram-negative rods are rarely
contaminants and should be treated, while treatment of gram-positive cocci
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psnet.ahrq.gov/node/49700/psn-pdf
February 01, 2014 - Any
evidence of ischemia should be aggressively treated in a patient with increasing ventricular arrhythmia … While all patients with NSVT should be optimally treated with beta-blockers
and revascularization whenever … possible (4,5), patients with high-risk NSVT should be treated with
intensified beta-blockade, provided
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - therapy is recommended for ischemic
stroke patients meeting criteria and presenting early enough to be treated … 1) Unfortunately, protocol deviations occur commonly in the community—in more than 50% of
patients treated … care, can drastically reduce protocol violations and improve both the numbers and safety of patients
treated
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - If the patient is suspected to be in adrenal crisis, they should be treated with high dose steroids immediately … Confirmatory testing is challenging after a patient has been treated with steroids (which suppress endogenous … abnormalities should be corrected; and hemodynamic instability or cardiopulmonary complications should be treated … Adrenal crisis must be treated immediately with high-dose steroids to prevent significant morbidity and
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - that the symptoms of pneumothorax, pain and dyspnea, are under-identified, under-quantified, and under-treated … only monitoring to “tension” pneumothorax with acute respiratory failure, shock, and even death if not treated … been performed, pain and dyspnea have been shown to be under-identified, under-quantified, and under-treated … fluoroscopy or other means to assess forcep location. 1 In the majority of cases, pneumothorax is treated