AHRQ Releases WebM&M

April 6, 2015    |   By: Calevir

The Agency for Healthcare Research and Quality has released the April WebM&M, morbidity & mortality rounds on the web.   Spotlighted case is “Dissecting the Presentation“, with additional cases: “Transition to Nowhere” and “Fire in the Hole! – An OR Fire“.

Surgical checklists are also addressed this month with an interview with Lucian Leape,MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, and an interview with David Urbach, MD, MSc, Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto.


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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