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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/node/40673/psn-pdf
September 03, 2011 - Evaluating efforts to optimize TeamSTEPPS
implementation in surgical and pediatric intensive care
units.
September 3, 2011
Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical
and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365-374.
htt…
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psnet.ahrq.gov/node/61110/psn-pdf
November 11, 2020 - Association between parent comfort with English and
adverse events among hospitalized children.
November 11, 2020
Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events
among hospitalized children. JAMA Pediatr. 2020;174(12):e203215.
doi:10.1001/jamapediatrics.2020.3215.…
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psnet.ahrq.gov/node/866691/psn-pdf
September 11, 2024 - Unlocking the potential of free text in electronic health
records with large language models (LLM): enhancing
patient safety and consultation interactions.
September 11, 2024
Kumarapeli P, Haddad T, de Lusignan S. Unlocking the potential of free text in electronic health records
with large language models (LLM): e…
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psnet.ahrq.gov/node/39392/psn-pdf
September 20, 2011 - Effect of point-of-care computer reminders on physician
behaviour: a systematic review.
September 20, 2011
Shojania KG, Jennings A, Mayhew A, et al. Effect of point-of-care computer reminders on physician
behaviour: a systematic review. CMAJ. 2010;182(5):E216-25. doi:10.1503/cmaj.090578.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45598/psn-pdf
November 23, 2016 - AHRQ Nursing Home Survey on Patient Safety Culture:
2016 User Comparative Database Report.
November 23, 2016
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare
Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
https://psnet.ahrq.gov/issue/ahrq-nursi…
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psnet.ahrq.gov/node/40600/psn-pdf
September 09, 2011 - To make or buy patient safety solutions: a resource
dependence and transaction cost economics perspective.
September 9, 2011
Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost
economics perspective. Health Care Manage Rev. 2011;36(4):288-298.
doi:10.1097/HMR.0b01…
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psnet.ahrq.gov/node/45488/psn-pdf
April 24, 2018 - National trends in safety performance of electronic health
record systems in children's hospitals.
April 24, 2018
Chaparro JD, Classen D, Danforth M, et al. National trends in safety performance of electronic health
record systems in children's hospitals. J Am Med Inform Assoc. 2017;24(2):268-274.
doi:10.1093/jami…
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psnet.ahrq.gov/node/37112/psn-pdf
May 26, 2011 - The impact of a closed-loop electronic prescribing and
administration system on prescribing errors,
administration errors and staff time: a before-and-after
study.
May 26, 2011
Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and
administration system on prescribing erro…
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psnet.ahrq.gov/node/41101/psn-pdf
October 16, 2012 - System-related interventions to reduce diagnostic errors:
a narrative review.
October 16, 2012
Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a
narrative review. BMJ Qual Saf. 2012;21(2):160-170. doi:10.1136/bmjqs-2011-000150.
https://psnet.ahrq.gov/issue/system-rel…
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psnet.ahrq.gov/node/45959/psn-pdf
June 29, 2017 - Impact of the Opioid Safety Initiative on opioid-related
prescribing in veterans.
June 29, 2017
Lin LA, Bohnert ASB, Kerns RD, et al. Impact of the Opioid Safety Initiative on opioid-related prescribing in
veterans. Pain. 2017;158(5):833-839. doi:10.1097/j.pain.0000000000000837.
https://psnet.ahrq.gov/issue/impact…
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psnet.ahrq.gov/node/38621/psn-pdf
February 18, 2011 - Process of care failures in breast cancer diagnosis.
February 18, 2011
Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen
Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0.
https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
Di…
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psnet.ahrq.gov/node/39294/psn-pdf
January 03, 2017 - Patient handoffs: standardized and reliable measurement
tools remain elusive.
January 3, 2017
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt
Comm J Qual Patient Saf. 2010;36(2):52-61.
https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-m…
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psnet.ahrq.gov/node/42154/psn-pdf
January 07, 2015 - Paper- and computer-based workarounds to electronic
health record use at three benchmark institutions.
January 7, 2015
Flanagan ME, Saleem JJ, Millitello LG, et al. Paper- and computer-based workarounds to electronic health
record use at three benchmark institutions. J Am Med Inform Assoc. 2013;20(e1):e59-66.
doi:…
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psnet.ahrq.gov/node/40907/psn-pdf
December 08, 2011 - Reporting of sentinel events in Swedish hospitals: a
comparison of severe adverse events reported by
patients and providers.
December 8, 2011
Öhrn A, Elfström J, Liedgren C, et al. Reporting of sentinel events in Swedish hospitals: a comparison of
severe adverse events reported by patients and providers. Jt Comm J…
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psnet.ahrq.gov/node/40200/psn-pdf
July 02, 2014 - Checklists to reduce diagnostic errors.
July 2, 2014
Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307-313.
doi:10.1097/ACM.0b013e31820824cd.
https://psnet.ahrq.gov/issue/checklists-reduce-diagnostic-errors
Diagnostic errors are rapidly gaining attention as the next f…
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psnet.ahrq.gov/node/37019/psn-pdf
September 15, 2011 - Just what the doctor ordered. Review of the evidence of
the impact of computerized physician order entry system
on medication errors.
September 15, 2011
Shamliyan TA, Duval S, Du J, et al. Just what the doctor ordered. Review of the evidence of the impact of
computerized physician order entry system on medication …
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psnet.ahrq.gov/node/41764/psn-pdf
January 18, 2013 - Examining the impact of the AHRQ Patient Safety
Indicators (PSIs) on the Veterans Health Administration:
the case of readmissions.
January 18, 2013
Rosen AK, Loveland S, Shin MH, et al. Examining the impact of the AHRQ Patient Safety Indicators (PSIs)
on the Veterans Health Administration: the case of readmissions…
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psnet.ahrq.gov/node/41935/psn-pdf
December 19, 2012 - Results of an effort to integrate quality and safety into
medical and nursing school curricula and foster joint
learning.
December 19, 2012
Headrick LA, Barton AJ, Ogrinc G, et al. Results of an effort to integrate quality and safety into medical and
nursing school curricula and foster joint learning. Health Aff (…
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psnet.ahrq.gov/node/46807/psn-pdf
July 02, 2019 - Communication failure: analysis of prescribers' use of an
internal free-text field on electronic prescriptions.
July 2, 2019
Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text
field on electronic prescriptions. J Am Med Inform Assoc. 2018;25(6):709-714. doi:1…