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1. Submit Case | PSNet
   psnet.ahrq.gov/submit-case-landing
   March 25, 2025 - Case Submission Benefits Case Selection Criteria Who Can Submit a Case? … Does the case have significant educational value? 5. … case. … An appropriate title for the case 2. … a commentary based on the case.

2. Mod5-Case-Scenarios (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-case-scenarios.pdf
   April 01, 2016 - .................................................................................................5 Case … Scenarios: Handling Challenging Communications Communication and Optimal Resolution Toolkit 2 – Case … Case Scenarios: Handling Challenging Communications – 5 Scenario 4: Disclosure After Event Analysis … The equipment is being used in this surgical case. … Two units of blood have been administered during the case using the equipment.

3. The Submit a Case Process | PSNet
   psnet.ahrq.gov/submit-case
   August 10, 2025 - The Submit a Case Process PSNet’s Submit a Case feature allows health care professionals to submit … Watch the video below to learn more about the Submit a Case process. … Submit Your Case   Audio-Described Version  (1 minute, 39 seconds)

4. The business case for quality: case studies and an analysis. | PSNet
   psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
   February 23, 2019 - Study Classic The business case for quality: case studies … The business case for quality: case studies and an analysis. … The authors examine four case studies to explore the financial and clinical implications of quality improvements … share the differing perspectives of the stakeholders to demonstrate how intimately tied a “business case … The business case for quality: case studies and an analysis.

5. Spotlight Case (ppt file)
   psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
   May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! … Case: Right? Left? Neither! … Case: Right? Left? Neither! … Case: Right? Left? Neither! … Case: Right? Left? Neither!

6. Spotlight Case (ppt file)
   psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
   October 01, 2009 - Spotlight Case Spotlight Case Difficult Encounters: A CMO and CNO Respond Source and Credits … This presentation is based on the October 2009 AHRQ WebM&M Spotlight Case See the full article at … Case: Difficult Encounters (2) On the afternoon following the cardiologist’s report, the orthopedic … the attending orthopedic surgeon to review x-rays of the case. … The attending then called the operating room to cancel the case.

7. Mod02-Business-Case-Worksheet (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/mod02-business-case-worksheet.pdf
   April 01, 2016 - business case tailored to the organization. … Organization’s> Business Case for Candor Recommended Business Case Elements Your Business Case Executive … for CANDOR Recommended Business Case Elements Your Business Case Current Climate Case Elements Your Business Case CANDOR Overview Case Elements Your Business Case Indirect Impact

8. Spotlight Case (ppt file)
   psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
   August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation … is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … test results Understand the hazards of alert fatigue in automated results management systems 3 4 Case … The pediatrician was busy all day long but near the end of the day found the result. 4 5 Case: No … She was given insulin and specific instructions on management at home. 5 6 Case: No News (3) The

9. Case-Management Executive (pdf file)
   effectivehealthcare.ahrq.gov/sites/default/files/related_files/case-management_executive.pdf
   January 01, 2013 - In the context of chronic illness care, they are central to the role of a case manager, but a case … , training, or skills of case managers. … Case Manager Functions Case managers typically performed multiple functions. … Case managers can help surmount these problems, but the role of the case manager is complex. … managers • Case manager experience • Specific functions of case managers and the distribution of

10. Tell Us How You've Used AHRQ Resources! | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/impact-case-study-stories.html
    December 01, 2019 - Add your story to AHRQ's Impact Case Studies Program! It's easy. … Let us know what AHRQ resource you used and we will work with you to develop an Impact Case Study. … Your experience will be shared with others on our Impact Case Studies Program Web page and via social

11. Use Case | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/use-case
    January 01, 2023 - Use Case Description A use case is a set of instructions that an individual in a process … IDENTIFY A PROCESS AND A SCENARIO within that process (the use case) to be analyzed. 2. … IDENTIFY STAKEHOLDERS AND KEY PLAYERS in the use case. 3. … COLLECT RELEVANT DATA that will aid in achieving the goals of the use case identified in the previous … ORGANIZE THE COLLECTED DATA in a manner which best supports the use case goals. 6.

12. Submit a Case | PSNet
    psnet.ahrq.gov/webmm/submit-case
    Submit a Case Note that your name will not be publicly associated with the case Breadcrumb … Submit a Case Case Form The content of case submissions is … your case to another site, please do so independent of your submission to AHRQ WebM&M. … edit the case. … your case to another site, please do so independent of your submission to AHRQ WebM&M.

13. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
    November 01, 2011 - Spotlight Case July 2008 Spotlight Case Near Miss with Bedside Medications * * Source and Credits … This presentation is based on the November 2011 AHRQ WebM&M Spotlight Case See the full article at … * * Case: Near Miss (3) The pharmacist came to the ED to teach the patient how to do subcutaneous … * * Background: Near Miss Multiple errors in this case Fortunately, patient was not harmed … This case can be defined as a near miss Near misses are unsafe acts that have the potential to injure

14. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
    February 01, 2013 - Spotlight Case July 2008 Spotlight Case Delay in Treatment: Failure to Contact Patient Leads to Significant … * * Source and Credits This presentation is based on the February 2013 AHRQ WebM&M Spotlight Case … * * Case: Failure to Contact (3) One week later, the patient went to the radiology department … similar health care provider or institution would or should do in the same circumstances Determined on case-by-case … participate in appropriate follow up There are no specific rules or guidelines; determination is made on a case-by-case

15. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
    August 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case August 2006 Physical Diagnosis: A Lost Art? … Source and Credits This presentation is based on the August 2006 AHRQ WebM&M Spotlight Case See the … Initial physical exam was recorded as follows: Case: Physical Diagnosis: A Lost Art? … Case (cont.): Physical Diagnosis: A Lost Art? … Case (cont.): Physical Diagnosis: A Lost Art?

16. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
    July 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case July 2004 Preventing Inappropriate Use of Novel Therapeutic … Agents Source and Credits This presentation is based on the July 2004 AHRQ WebM&M Spotlight Case … Case: Novel Drug Misuse A 48-year-old man was admitted to the intensive care unit after a motor vehicle … Case (cont.): Novel Drug Misuse Post-operatively, the patient developed renal failure; an APACHE II … Case (cont.): Novel Drug Misuse Eighteen hours after infusion, the patient developed severe bleeding

17. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.242_slideshow.ppt
    June 01, 2011 - Spotlight Case July 2008 Spotlight Case The ECG is Not Normal * * Source and Credits This presentation … is based on the June 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … relatives Appreciate some of the steps hospitals take to prevent identification errors * * Case … ” * * Case: ECG Not Normal (2) “The ECG was performed, and as we were leaving the office I asked … ” * * Case: ECG Not Normal (3) “My mind raced, filled with the worst diseases I could imagine.

18. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
    January 01, 2009 - Spotlight Case July 2008 Spotlight Case January 2009 To Transfer or Not to Transfer Source and … Credits This presentation is based on the January 2009 AHRQ WebM&M Spotlight Case See the full article … diversion and federal EMTALA statutes Identify ways to improve continuity of hospital care Case … Case: To Transfer or Not (3) The patient told paramedics that he had just been discharged and received … Issues from Case Safety for prehospital, emergency department (ED), and hospital care Did decision

19. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
    May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and … Credits This presentation is based on the May 2011 AHRQ WebM&M Spotlight Case See the full article … * * Case: Duty to Disclose (2) Over the next 24 hours, the child became increasingly confused … * * Case: Duty to Disclose (3) He was transferred from this hospital to a tertiary care center … * * Case: Duty to Disclose (5) When it was clear the child could not survive, the pediatricians

20. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
    May 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer … * * Source and Credits This presentation is based on the May 2010 AHRQ WebM&M Spotlight Case See … response to an error Distinguish accountability for failure and learning from failure * * Case … * Case: Fatal Error in Neonate (3) Within 4 hours of starting the lipid emulsion through the TPN … * The Present Case The case is severe and shocking, as is the outcome: the death of a infant In