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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - November 16, 2022
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - January 1, 2014
Annual Perspective
Patient Safety and Opioid
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - October 31, 2011
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - osteoarthritis, and spinal stenosis, status/post two previous
spine surgeries and long-term use of opioid
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www.ahrq.gov/patient-safety/reports/engage/methods.html
March 01, 2017 - Diagnostic errors
Medication prescription, management, drug interactions, adherence
Antibiotic, opioid
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - special interest in patient safety and he has authored papers on quality improvement in intensive care, opioid-free
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - Recurrent Pneumothorax
August 25, 2021
Lessons learned in implementing a chronic opioid
-
www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-digital.html
May 01, 2024 - Care for Children
P12: Using a Televideo-based Training Model for Providers to Expand Treatment for Opioid
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
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hcup-us.ahrq.gov/reports/natstats/his95/table1a.htm
January 01, 1996 - $4,142 $2,113 $3,011 $4,586 5.1 0.0 62.1 36.1
5.2.2.1 Opioid
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hcup-us.ahrq.gov/reports/natstats/his96/table1a.htm
January 01, 1996 - $4,142 $2,113 $3,011 $4,586 5.1 0.0 62.1 36.1
5.2.2.1 Opioid
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - Quickly Adopted but Questions Remain
January 1, 2006
Incident and long-term opioid
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-262-pharmacotherapy-alcohol-disposition-comments.pdf
November 07, 2023 - As written
the phrase beginning with showing seems to apply to opioid receptor sites and not
to naltrexone
-
www.ahrq.gov/data/apcd/backgroundrpt/review.html
July 01, 2022 - Topics of great interest included high-cost populations and the opioid addiction problem.
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - December 23, 2020
A mixed-methods analysis of patient safety incidents involving opioid
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/novel-drug-misuse
September 30, 2010 - WebM&M Cases
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Delayed Diagnosis of Mesenteric Ischemia
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc
o AHRQ WebM&M…