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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - Many such reports, for instance ones involving opiates or anticoagulants, capture problems that occur
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - Spotlight
Spotlight
Lost in Transitions of Care: Managing an
Opioid-Dependent Patient with Frequent
Hospitalizations
Source and Credits
• This presentation is based on the September 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary …
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psnet.ahrq.gov/glossary
January 01, 2003 - Glossary
A B C D E F H I J L M N O P R S T U V W
Active Error (or Active Failure)
The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a humanâmachine in…
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psnet.ahrq.gov/glossary-0
January 01, 2003 - Glossary
Definitions abound in the medical error and patient safety literature, with subtle and not-so-subtle variations in the meanings of important terms. An effort was made to adopt the most straightforward terminology, with definitions that enjoy the widest use.
A B C D E F H I J L M N O P R S T U…
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - See More About The Topic
Hospitals
Facility and Group Administrators
Medicine
Opiates
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
CE/MOC
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
PPT
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Florence Tan, Pharm…
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - Many such reports, for instance ones involving opiates or anticoagulants, capture problems that occur