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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx
Spotlight
Challenging Case of Multiple Suicide Attempts in a
Complex Patient with Psychiatric Comorbidities
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://…
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psnet.ahrq.gov/node/72744/psn-pdf
February 17, 2021 - Association between in-clinic opioid administration and
discharge opioid prescription in urgent care: a
retrospective cohort study.
February 17, 2021
Calcaterra SL, Lou Y, Everhart RM, et al. Association between in-clinic opioid administration and discharge
opioid prescription in urgent care: a retrospective cohor…
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psnet.ahrq.gov/node/866866/psn-pdf
October 02, 2024 - New Analysis Shows Hospitals Improving Performance
on Key Patient Safety Measures Surpassing Pre-
pandemic Levels.
October 2, 2024
New Analysis Shows Hospitals Improving Performance On Key Patient Safety Measures Surpassing Pre-
Pandemic Levels. Chicago, IL: American Hospital Association; September 2024.
https://…
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - is bundled payments, in which hospitals and postacute care
facilities split a single payment for an episode … Bundled payments
in California had little or no effect due to difficulty in defining the acute care episode
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psnet.ahrq.gov/node/838127/psn-pdf
September 21, 2022 - Opioid dependence and overdose after surgery: rate, risk
factors, and reasons.
September 21, 2022
Wylie JA, Kong L, Barth RJ. Opioid dependence and overdose after surgery: rate, risk factors, and
reasons. Ann Surg. 2022;276(3):e192-e198. doi:10.1097/sla.0000000000005546.
https://psnet.ahrq.gov/issue/opioid-depende…
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - obesity, and previously untreated hypertension who presented to the emergency department (ED) for an episode … and William Frick, MD This patient with previously untreated hypertension presented after a syncopal episode … without treatment and severe heart failure with an ejection fraction of about 20% before her syncopal episode
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psnet.ahrq.gov/node/46276/psn-pdf
August 02, 2017 - Vital signs: changes in opioid prescribing in the United
States, 2006-2015.
August 2, 2017
Guy GP, Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-
2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704. doi:10.15585/mmwr.mm6626a4.
https://psnet.ahrq.gov/issue/vital-sig…
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psnet.ahrq.gov/node/43918/psn-pdf
September 27, 2017 - Medication-administration errors in an urban mental
health hospital: a direct observation study.
September 27, 2017
Cottney A, Innes J. Medication-administration errors in an urban mental health hospital: a direct
observation study. Int J Ment Health Nurs. 2015;24(1):65-74. doi:10.1111/inm.12096.
https://psnet.ahr…
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psnet.ahrq.gov/node/40736/psn-pdf
January 04, 2012 - Preventing wrong site, procedure, and patient events
using a common cause analysis.
January 4, 2012
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a
common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/1062860611412066.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/46170/psn-pdf
July 12, 2017 - Missed nursing care in pediatrics.
July 12, 2017
Lake ET, de Cordova PB, Barton S, et al. Missed Nursing Care in Pediatrics. Hosp Pediatr. 2017;7(7):378-
384. doi:10.1542/hpeds.2016-0141.
https://psnet.ahrq.gov/issue/missed-nursing-care-pediatrics
Missed nursing care is common and has been linked to adverse events…
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - is bundled payments, in which hospitals and postacute care facilities split a single payment for an episode … Bundled payments in California had little or no effect due to difficulty in defining the acute care episode
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode
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psnet.ahrq.gov/node/46819/psn-pdf
January 27, 2019 - Implementing electronic health record default settings to
reduce opioid overprescribing: a pilot study.
January 27, 2019
Zivin K, White JO, Chao S, et al. Implementing Electronic Health Record Default Settings to Reduce Opioid
Overprescribing: A Pilot Study. Pain Med. 2019;20(1):103-112. doi:10.1093/pm/pnx304.
htt…
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psnet.ahrq.gov/node/39192/psn-pdf
February 02, 2011 - Contraindicated medication use in dialysis patients
undergoing percutaneous coronary intervention.
February 2, 2011
Tsai TT, Maddox TM, Roe MT, et al. Contraindicated medication use in dialysis patients undergoing
percutaneous coronary intervention. JAMA. 2009;302(22):2458-64. doi:10.1001/jama.2009.1800.
https://p…
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psnet.ahrq.gov/issue/influencing-culture-learning-diagnostic-errors-health-system
April 22, 2021 - Upcoming Meeting/Conference
June 23, 2021
Influencing a Culture of Learning from Diagnostic Errors at a Health System.
Citation Text:
Patient Safety Authority. July 21, 2021. 12:00-1:00 PM (eastern).
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psnet.ahrq.gov/node/73364/psn-pdf
January 01, 2022 - Impact of opioid administration in the intensive care unit
and subsequent use in opioid-naïve patients.
June 9, 2021
Krancevich NM, Belfer JJ, Draper HM, et al. Impact of opioid administration in the intensive care unit and
subsequent use in opioid-naïve patients. Ann Pharmacother. 2022;56(1):52-59.
doi:10.1177/10…
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psnet.ahrq.gov/node/849125/psn-pdf
May 17, 2023 - Vestibular syndromes, diagnosis and diagnostic errors in
patients with dizziness presenting to the emergency
department: a cross-sectional study.
May 17, 2023
Comolli L, Korda A, Zamaro E, et al. Vestibular syndromes, diagnosis and diagnostic errors in patients with
dizziness presenting to the emergency department…
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psnet.ahrq.gov/node/37655/psn-pdf
September 24, 2010 - Reducing anticoagulant medication adverse events and
avoidable patient harm.
September 24, 2010
Jennings HR, Miller EC, Williams TS, et al. Reducing anticoagulant medication adverse vents and
avoidable patient harm. Jt Comm J Qual Patient Saf. 2008;34(4):196-200.
https://psnet.ahrq.gov/issue/reducing-anticoagulant…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - It should be noted that most patients have at least one episode of increased pain after the use of methotrexate … Physicians should be aware that most patients will experience at least one episode of increased pain
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…