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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx
Spotlight
A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
Source and Credits
• This presentation is based on the July 2023 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - ems-protocols-all-paramedics-should-follow-7c1zyNEC6v1SjDQM/#:~:text=The%20purpose%20of%20EMS%20protocols,assessing
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psnet.ahrq.gov/node/837744/psn-pdf
July 27, 2022 - Medication orders with future start dates: how far away is
too far?
July 27, 2022
ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4.
https://psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far
Human errors that occur while interacting with electronic health recor…
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psnet.ahrq.gov/node/867049/psn-pdf
October 30, 2024 - National Review of Maternity Services in England 2022 to
2024.
October 30, 2024
National Review Of Maternity Services In England 2022 To 2024. Newcastle Upon Tyne, UK: Care Quality
Commission; September 2024.
https://psnet.ahrq.gov/issue/national-review-maternity-services-england-2022-2024
Maternal safety is a gl…
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/45275/psn-pdf
November 01, 2017 - Electronic tools to support medication reconciliation—a
systematic review.
November 1, 2017
Marien S, Krug B, Spinewine A. Electronic tools to support medication reconciliation: a systematic review. J
Am Med Inform Assoc. 2017;24(1):227-240. doi:10.1093/jamia/ocw068.
https://psnet.ahrq.gov/issue/electronic-tools-s…
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psnet.ahrq.gov/node/46298/psn-pdf
October 18, 2017 - CVS taps a design legend to reinvent the prescription
label. Next stop: the pharmacy.
October 18, 2017
Kuang C. Fast Company. October 4, 2017.
https://psnet.ahrq.gov/issue/cvs-taps-design-legend-reinvent-prescription-label-next-stop-pharmacy
Complicated systems often require more than one change to improve their s…
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psnet.ahrq.gov/node/46711/psn-pdf
July 01, 2019 - The STOP Measure. Safe and Transparent Opioid
Prescribing to Promote Patient Safety and Reduced Risk
of Opioid Misuse.
July 1, 2019
Washington, DC: America's Health Insurance Plans; 2019.
https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety-
and-reduced-risk
Gu…
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psnet.ahrq.gov/node/47758/psn-pdf
April 17, 2019 - Contribution of adverse events to death of hospitalised
patients.
April 17, 2019
Haukland EC, Mevik K, von Plessen C, et al. Contribution of adverse events to death of hospitalised
patients. BMJ Open Qual. 2019;8(1):e000377. doi:10.1136/bmjoq-2018-000377.
https://psnet.ahrq.gov/issue/contribution-adverse-events-de…
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psnet.ahrq.gov/node/35402/psn-pdf
September 10, 2009 - Can patients be part of the solution? Views on their role
in preventing medical errors.
September 10, 2009
Hibbard JH, Peters E, Slovic P, et al. Can patients be part of the solution? Views on their role in preventing
medical errors. Med Care Res Rev. 2005;62(5):601-16.
https://psnet.ahrq.gov/issue/can-patients-be…
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…
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psnet.ahrq.gov/node/40097/psn-pdf
January 19, 2011 - Use of an electronic information system to identify
adverse events resulting in an emergency department
visit.
January 19, 2011
Ackroyd-Stolarz S, MacKinnon NJ, Zed PJ, et al. Use of an electronic information system to identify
adverse events resulting in an emergency department visit. Qual Saf Health Care. 2010;1…
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psnet.ahrq.gov/node/47213/psn-pdf
June 20, 2018 - Are second victims getting the help they need?
June 20, 2018
Headley M. Patient Saf Qual Healthc. May/June 2018.
https://psnet.ahrq.gov/issue/are-second-victims-getting-help-they-need
Clinicians can experience emotional stress, guilt, and insecurity after making a mistake. Organizations are
increasingly building p…
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psnet.ahrq.gov/node/50653/psn-pdf
November 13, 2019 - A national patient safety curriculum in pediatric
emergency medicine.
November 13, 2019
Stankovic C, Wolff M, Chang TP, et al. A National Patient Safety Curriculum in Pediatric Emergency
Medicine. Pediatr Emerg Care. 2019;35(8):519-521. doi:10.1097/PEC.0000000000001533.
https://psnet.ahrq.gov/issue/national-patien…
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psnet.ahrq.gov/node/46278/psn-pdf
July 19, 2017 - The opioid epidemic: what can surgeons do about it?
July 19, 2017
Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18.
https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it
Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
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psnet.ahrq.gov/node/50445/psn-pdf
October 09, 2019 - A demonstration project on the impact of safety culture
on infection control practices in hemodialysis
October 9, 2019
Millson T, Hackbarth D, Bernard HL. A demonstration project on the impact of safety culture on infection
control practices in hemodialysis. Am J Infect Control. 2019;47(9):1122-1129.
doi:10.1016/j…
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psnet.ahrq.gov/node/60020/psn-pdf
March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills
performance improvement.
March 4, 2020
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance
Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
https://psnet.ahrq.gov/issue/enotss-platform-s…
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psnet.ahrq.gov/node/46025/psn-pdf
July 11, 2017 - Measuring to improve medication reconciliation in a large
subspecialty outpatient practice.
July 11, 2017
Kern E, Dingae MB, Langmack EL, et al. Measuring to Improve Medication Reconciliation in a Large
Subspecialty Outpatient Practice. Jt Comm J Qual Patient Saf. 2017;43(5):212-223.
doi:10.1016/j.jcjq.2017.02.005…
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psnet.ahrq.gov/node/60764/psn-pdf
August 05, 2020 - As coronavirus ravaged nursing homes, inspectors were
not being tested.
August 5, 2020
Dolan J, Mejia B. As coronavirus ravaged nursing homes, inspectors were not being tested. Los Angeles
Times. 2020;July 24.
https://psnet.ahrq.gov/issue/coronavirus-ravaged-nursing-homes-inspectors-were-not-being-tested
Worker s…
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psnet.ahrq.gov/node/45263/psn-pdf
September 04, 2016 - PSYCH: a mnemonic to help psychiatric residents
decrease patient handoff communication errors.
September 4, 2016
Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease
Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016;42(7):316-320.
https://psnet.ahrq.gov/i…