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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Another Fall
April 1, 2003
Bogardus SG. Another Fall. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/another-fall
Case Objectives
List risk factors for falls in hospitalized patients
Understand appropriate use of restraints
Identify system issues contributing to falls in hospitalized patients
Case & Comm…
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In 16 states, citizens have been instrumental in securing passage of legislation on reporting of hospital
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - Missed Patient Assignment: Is Anyone There?
Citation Text:
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google …
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - required the IOM report—particularly its made-for-TV analogy that the deaths from medical mistakes in the United … States were the equivalent of a jumbo jet crashing every day—to ultimately spark the safety movement
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - PDMPs, presently available in 49 states, are state-run electronic databases used to track pharmacy dispensing … Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008.
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psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-elderly-veterans-are-we-using-wrong-drug-wrong-dose-or
August 15, 2012 - June 19, 2013
Infant deaths associated with cough and cold medications—two states, 2005
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psnet.ahrq.gov/issue/influence-structure-and-culture-medical-group-practices-prescription-drug-errors
January 14, 2011 - June 16, 2019
Ambulatory prescribing errors among community-based providers in two states
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psnet.ahrq.gov/issue/medication-errors-resulting-computer-entry-nonprescribers
January 02, 2017 - Study
Medication errors resulting from computer entry by nonprescribers.
Citation Text:
Santell JP, Kowiatek JG, Weber RJ, et al. Medication errors resulting from computer entry by nonprescribers. Am J Health Syst Pharm. 2009;66(9):843-53. doi:10.2146/ajhp080208.
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…
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psnet.ahrq.gov/issue/explaining-unexplainable-impact-physicians-attitude-towards-litigation-their-incident
March 26, 2014 - Study
Explaining the unexplainable—the impact of physicians' attitude towards litigation on their incident disclosure behaviour.
Citation Text:
Renkema E, Broekhuis MH, Ahaus K. Explaining the unexplainable - the impact of physicians' attitude towards litigation on their incident disclos…
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psnet.ahrq.gov/issue/frequency-prescribing-errors-medical-residents-various-training-programs
November 05, 2014 - Study
Frequency of prescribing errors by medical residents in various training programs.
Citation Text:
Honey BL, Bray WM, Gomez MR, et al. Frequency of prescribing errors by medical residents in various training programs. J Patient Saf. 2015;11(2):100-4. doi:10.1097/PTS.0000000000000048…
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psnet.ahrq.gov/issue/identifying-hospital-organizational-strategies-reduce-readmissions
May 25, 2016 - Study
Identifying hospital organizational strategies to reduce readmissions.
Citation Text:
Ahmad FS, Metlay JP, Barg FK, et al. Identifying hospital organizational strategies to reduce readmissions. Am J Med Qual. 2013;28(4):278-85. doi:10.1177/1062860612464999.
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F…
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psnet.ahrq.gov/issue/characteristics-medical-professional-liability-claims-against-internists
April 21, 2010 - Study
Characteristics of medical professional liability claims against internists.
Citation Text:
Mangalmurti SS, Harold JG, Parikh PD, et al. Characteristics of medical professional liability claims against internists. JAMA Intern Med. 2014;174(6):993-5. doi:10.1001/jamainternmed.2014.1…
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psnet.ahrq.gov/issue/association-between-opioid-prescribing-patterns-and-abuse-ophthalmology
April 12, 2019 - wrote fewer than 10 opioid prescriptions per year, but a small group, concentrated in the Southern states
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
March 24, 2021 - Study
Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.
Citation Text:
McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53.
Copy Citation…
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psnet.ahrq.gov/issue/more-feeling-role-empathetic-care-promoting-safety-health-care
June 23, 2021 - May 25, 2016
The Pennsylvania Learning Exchange: Helping States Improve and Integrate
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psnet.ahrq.gov/issue/transition-traditional-code-team-medical-emergency-team-and-categorization-cardiopulmonary
January 06, 2017 - Study
Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center.
Citation Text:
Hunt EA, Zimmer KP, Rinke ML, et al. Transition from a traditional code team to a medical emergency team and categorization of …
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psnet.ahrq.gov/issue/inadequate-emergency-department-care-and-physician-misconduct-washington-dc-va-medical-center
September 30, 2020 - September 6, 2023
Hospitals in two states denied an abortion to a miscarrying patient