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psnet.ahrq.gov/issue/hospitals-overhaul-ers-reduce-mistakes
August 17, 2016 - WebM&M Cases
The Dose Makes the Poison: Medication Error During Procedural Sedation
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psnet.ahrq.gov/issue/speak-initiative
February 28, 2018 - June 16, 2021
Design and implementation of an analgesia, sedation, and paralysis order
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Although given medications for sedation, the patient
was disoriented, and restraints were placed on … the patient's
fall risk screening or other assessment information needed to determine her level of sedation … hospitalized patients are often at risk for falls because of medication-related disorientation or
sedation … Multiple interventions can be employed to address such disorientation and sedation, including
frequent
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psnet.ahrq.gov/issue/ucsd-doc-who-overdosed-hospital-bathroom-face-lawsuits
March 27, 2024 - March 30, 2022
A widow’s mission to change NC dental sedation rules.
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psnet.ahrq.gov/issue/artificial-intelligence-rushing-patient-care-and-could-raise-risks
July 15, 2020 - March 30, 2022
A widow’s mission to change NC dental sedation rules.
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psnet.ahrq.gov/issue/pediatric-medication-errors-and-reduction-strategies-perioperative-period
October 19, 2022 - June 20, 2011
Preprinted order sets as a safety intervention in pediatric sedation.
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psnet.ahrq.gov/issue/survey-ohio-regulator-shows-stress-fatigue-among-pharmacists-chain-stores
November 09, 2022 - March 30, 2022
A widow’s mission to change NC dental sedation rules.
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psnet.ahrq.gov/issue/errors-and-analysis-errors
August 28, 2019 - May 27, 2011
Preprinted order sets as a safety intervention in pediatric sedation.
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psnet.ahrq.gov/issue/technology-education-and-safety-3
October 11, 2023 - November 3, 2015
Risk factors for adverse events in emergency department procedural sedation
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psnet.ahrq.gov/issue/perianesthesia-nursing-advocacy-influential-voice-patient-safety
June 08, 2022 - April 6, 2011
Nurse reports of adverse events during sedation procedures at a pediatric
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - Slide 10
Say:
Michelle was to have an endoscopic gastrointestinal procedure under heavy-
moderate sedation … cardiopulmonary arrest,
but during the code, Michelle had no response to reversal agents used for the
sedation … ■ The American Society of Anesthesiology adopted the standard that
capnography be used in heavy sedation … Illinois at Chicago adopted improved policies regarding
anesthesia coverage for cases involving heavy sedation
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psnet.ahrq.gov/issue/pediatric-perioperative-medication-errors
July 10, 2024 - Swap
May 1, 2011
Preprinted order sets as a safety intervention in pediatric sedation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/dailygoals.docx
January 01, 2003 - Patient Care
Pain management/sedation (held to follow commands)?
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psnet.ahrq.gov/issue/safety-and-reliability-pediatrics
December 06, 2011 - April 26, 2023
Risk factors for adverse events in emergency department procedural sedation
-
psnet.ahrq.gov/issue/2014-john-m-eisenberg-patient-safety-and-quality-award-recipients-announced
February 28, 2018 - June 16, 2021
Design and implementation of an analgesia, sedation, and paralysis order
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psnet.ahrq.gov/issue/dangerous-connections-health-care-community-tackles-tubing-risks-small-bore-connector
October 26, 2007 - July 13, 2022
Design and implementation of an analgesia, sedation, and paralysis order
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psnet.ahrq.gov/issue/drug-error-eskenazi-hospital-killed-prominent-cancer-researcher-heres-how-it-happened
September 09, 2015 - March 30, 2022
A widow’s mission to change NC dental sedation rules.
-
psnet.ahrq.gov/issue/human-factors-pediatric-anesthesia-incidents
June 06, 2018 - October 5, 2011
Preprinted order sets as a safety intervention in pediatric sedation.
-
psnet.ahrq.gov/issue/national-patient-safety-goals
May 30, 2012 - July 13, 2022
Design and implementation of an analgesia, sedation, and paralysis order
-
psnet.ahrq.gov/issue/iatrogenic-harm-cost-equation-and-new-technology
January 24, 2024 - August 23, 2023
Threats to safety during sedation outside of the operating room and the