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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - Safety and Quality
April 26, 2023
Design and implementation of an analgesia, sedation
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - April 15, 2020
Enhancing patient safety during pediatric sedation: the impact of simulation-based
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psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - WebM&M Cases
The Dose Makes the Poison: Medication Error During Procedural Sedation
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hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
January 01, 2016 - Obstetric Delivery Inpatient Stays Involving Substance Use Disorders and Related Clinical Outcomes, 2016
1
October 2019
Obstetric Delivery Inpatient Stays Involving
Substance Use Disorders and Related
Clinical Outcomes, 2016
Anita Soni, Ph.D., M.B.A., Kathryn R. Fingar, Ph.D., M.P.H., and
Law…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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effectivehealthcare.ahrq.gov/sites/default/files/cer-251-integrated-pain-management-evidence-summary.pdf
October 01, 2021 - Intergrated and Comprehensive Pain Management Programs: Effectiveness and Harms: Evidence Summary
Comparative Effectiveness Review
Number 251
Integrated and Comprehensive Pain
Management Programs: Effectiveness and
Harms
Evidence Summary
Main Points
Background and Purpose
Pain affects millions …
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psnet.ahrq.gov/node/867427/psn-pdf
December 18, 2024 - The Ongoing Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
Falls are not a new issue, especially among older adults. The Centers for D…
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
July 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case July 2006
Moving Pains
Source and Credits
This presentation is based on the June/July 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Hildy Schell, RN, MS, CCRN, CCNS, and…
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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - Toxic Tachycardia
October 1, 2007
Wartofsky L. Toxic Tachycardia. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/toxic-tachycardia
The Case
A 66-year-old woman with a past medical history of hypertension and breast cancer was admitted with
abdominal pain. She complained of 3 weeks of progressive severe rig…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Ci…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/labor-nitrous-oxide_executive.pdf
August 01, 2012 - given intravenously or by
intramuscular injection
• Provides some relief of labor pain and
causes sedation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/ascwebcast0715_transcript.pdf
September 01, 2015 - require general
anesthesia, and a nonsurgical procedure would be an endoscopy that would require mild sedation … intraop concern would be if the recovery nurse has a question regarding
the patient’s response to sedation … In regard to staff training, we covered areas of IV
insertion, conscious sedation, scope reprocessing
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effectivehealthcare.ahrq.gov/sites/default/files/peptic-ulcer-horizon-scan-high-impact-1306.pdf
June 01, 2013 - If the procedure becomes an outpatient procedure
performed under twilight sedation (more commonly known … as conscious sedation), as one clinical
expert from a facility with POEMs experience noted, the care-setting … The expert thought that POEM could be performed in an endoscopy suite under
moderate sedation and could
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effectivehealthcare.ahrq.gov/sites/default/files/nonopioid-chronic-pain-ape_0.xlsx
August 08, 2017 - -0.00 (-0.01 to 0.00)
Cognitive disturbance: SMD -0.16 (-0.21 to -0.10)
Nausea: 0.16 (0.14 to 0.19)
Sedation … placebo RD (95% CI)
WAE: -0.03 (-0.09 to 0.04)
SAE:0.00 (-0.05 to 0.05)
Nausea: 0.04 (-0.10 to 0.18)
Sedation … 0.00 (-0.01 to 0.01)
Cognitive disturbances: SMD -0.27 (-0.38 to -0.16)
Nausea: 0.19 (0.15 to 0.22)
Sedation
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www.ahrq.gov/sites/default/files/2024-01/wessell2-report.pdf
January 01, 2024 - Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids in Primary Care
Final Progress Report
Reducing Adverse Drug Events from Anticoagulants, Diabetes Agents and Opioids in
Primary Care
Principal Investigator: Andrea M. Wessell, PharmD
Team Members: Steven M. Orns…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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hcup-us.ahrq.gov/reports/statbriefs/sb158.pdf
August 11, 2013 - Origin of Adverse Drug Events in U.S. Hospitals, 2011
1
July 2013
Origin of Adverse Drug Events in U.S.
Hospitals, 2011
Audrey J. Weiss, Ph.D., Anne Elixhauser, Ph.D., Jaeyong Bae,
M.A., and William Encinosa, Ph.D.
Introduction
Prescription medications are widely used to treat a variety…