AHRQ Web M&M Released

December 13, 2013    |   By: Calevir

EHRs and safety plus case studies on oral anticoagulants, anesthesia machines during CABG and improving quality of care in SNFs

This month, the AHRQ Web M&M highlight a Perspectives on Safety covering patient safety research, discussing electronic health record-related patient safety issues and diagnostic errors. Spotlight cases include “New Oral Anticoagulants,” and interactions with other medication,  “Check the Anesthesia Machine,” a case in which the anesthesia machine was delivering something more than oxygen and “SNFs: Opening the Black Box,” discussing the re hospitalization of an elderly woman that was discharged to killed care, noting strategies to improve quality of care in skilled nursing facilities.


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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