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3741. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33830/psn-pdf
      March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…

3742. A Sweet Case of Hidden Hydrogen Ions | PSNet
      psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
      November 30, 2023 - November 30, 2023 Influence of opioid prescription policy on overdoses and related … April 15, 2016 Prescription opioid dose reductions and potential adverse events: a multi-site

3743. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846169/psn-pdf
      March 15, 2023 - The anesthesiologist was distracted briefly by the anesthesia technologist to sign for opioid drugs … distractions for the anesthesiologist The anesthesiologist in this case was distracted by having to sign for opioid

3744. The Role of Community Pharmacists in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
      October 24, 2021 - Pharmacists must identify patients at risk for fatal overdose and facilitate access to the emergency opioid … the positive impact of pharmacists on preventative care such as health screenings and immunizations, opioid … understand why they're taking their therapy, or counseling on controlled substance utilization or even opioid

3745. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72616/psn-pdf
      December 22, 2020 - adverse-events-dentistry https://psnet.ahrq.gov//#_edn1 https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry

3746. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33586/psn-pdf
      December 15, 2024 - impact-national-qi-programme-reducing-electronic-health-record-notifications-clinicians https://psnet.ahrq.gov/issue/clinically-inconsequential-alerts-characteristics-opioid-drug-alerts-and-their-utility

3747. Readmissions and Adverse Events After Discharge | PSNet
      psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
      April 27, 2022 - Preventable Transfer to the Hospital July 8, 2022 Lost in Transitions of Care: Managing an Opioid-Dependent

3748. Diagnostic Errors | PSNet
      psnet.ahrq.gov/primer/diagnostic-errors
      June 15, 2024 - Framing effects Diagnostic decision-making unduly biased by subtle cues and collateral information A with opioid

3749. Leadership Role in Improving Safety | PSNet
      psnet.ahrq.gov/primer/leadership-role-improving-safety
      September 15, 2024 - Tools March 15, 2025 Patient Safety Primers Opioid

3750. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
      psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
      January 29, 2021 - The anesthesiologist was distracted briefly by the anesthesia technologist to sign for opioid drugs in … for the anesthesiologist The anesthesiologist in this case was distracted by having to sign for opioid

3751. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
      May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…

3752. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet
      psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
      August 14, 2024 - osteoarthritis, and spinal stenosis, status/post two previous spine surgeries and long-term use of opioid … WebM&M Cases Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced

3753. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet
      psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
      January 07, 2022 - Delayed Diagnosis June 24, 2020 Healthcare system-wide implementation of opioid-safety … guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related

3754. Spotlight
      psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
      January 01, 2025 - Overview (3) Given a history of previous abdominal operations, severe abdominal pain not responsive to opioid … observation unit for further treatment, especially given his continued guarding on reassessment despite opioid

3755. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient Kristine Markham … Inadvertent dose stacking and opioid polypharmacy may have contributed to this patient’s death.

3756. In Conversation With… Richard Platt, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
      October 01, 2016 - build systems that would make it much easier to identify patients who are at risk for problems with opioid … dependence or complications of opioid therapy that would guide clinicians with better prescribing.

3757. Computerized Provider Order Entry and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
      January 01, 2014 - January 1, 2014 Annual Perspective Patient Safety and Opioid

3758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867672/psn-pdf
      February 26, 2025 - Given a history of previous abdominal operations, severe abdominal pain not responsive to opioid analgesia … observation unit for further treatment, especially given his continued guarding on reassessment despite opioid

3759. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet
      psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
      September 27, 2023 - Given a history of previous abdominal operations, severe abdominal pain not responsive to opioid analgesia … observation unit for further treatment, especially given his continued guarding on reassessment despite opioid

3760. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49824/psn-pdf
      March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…