AHRQ’s Perspectives on Safety

February 7, 2012    |   By: Calevir

Lawrence Smith, MD, founding dean of the Hofstra North Shore-LIJ School of Medicine, recently gave an  interview, on resident supervision and patient safety. Listen to an excerpt online or download a podcast. An accompanying  perspective piece, by C. Jessica Dine, MD, MA, and Jennifer S. Myers, MD, University of Pennsylvania, examine how increased supervision influences the educational experience for trainees.

E-prescribing: E for error?” A canceled electronic prescription went through to the pharmacy anyway, and the patient received it. Elisa W. Ashton, PharmD, of UCSF, addresses risks and benefits associated with e-prescribing.

Poorly Advanced Directives,” Wendy G. Anderson, MD, MS, of UCSF, explores the limitations of DNR orders and emphasizes the importance of advance care planning discussions.

Amended Lab Results: Communication Slip,” a pregnant woman with new onset hypertension and proteinuria was set to be discharged but a later amended medical report showed her results were elevated and abnormal, confirming a diagnosis of preeclampsia. Vanitha Janakiraman Mohta, MD, of Kaiser Permanente, discusses challenges surrounding communication of amended laboratory results.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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