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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. 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)

3. 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.

4. 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!

5. 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.

6. 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

7. 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.

8. 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

9. 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

10. 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?

11. 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

12. 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.

13. 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

14. 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

15. 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

16. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
    May 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case May 2005 Diagnosing Diagnostic Mistakes Source and … Credits This presentation is based on the May 2005 AHRQ WebM&M Spotlight Case See the full article … WebM&M Case Analysis The case is considered to “dramatically and tragically” illustrate a diagnostic … She later dies of an aortic dissection and the case is presented as a diagnostic error. … WebM&M Case Analysis Initial diagnosis of acute coronary syndrome reasonable due to lower base rates

17. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
    May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error … * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case … * * Case: Right Regimen, Wrong Cancer (2) In the morning his bedside nurse for the day came in … * * Case: Right Regimen, Wrong Cancer (3) Rather than the 3-day regimen for metastatic penile … Informed patients can catch some errors, as in this case. *

18. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
    February 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case February 2006 Lost in Transition Source and Credits … This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case See the full article at … of transitions in emergency care Provide suggestions to decrease risk at shift transitions Case … Case (cont.): Lost in Transition Sixty minutes after arrival, the patient was admitted to the internal … Case (cont.): Lost in Transition The outgoing ED physician had just completed the shift, and signed

19. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
    April 01, 2009 - Spotlight Case July 2008 Spotlight Case Breakage of a PICC Line * * Source and Credits This … presentation is based on the April 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … breakage Understand the risk factors for PICC line breakage Understand the treatment options in case … Appreciate the guidelines to reduce risk of complications from central venous catheters * * Case … * * Case: PICC Line Breakage (3) After several attempts to retrieve the remainder of the line

20. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
    September 01, 2008 - Spotlight Case July 2008 Spotlight Case Empiric Steroids: the Good, the Bad, and the Ugly Source … and Credits This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case See the full … Understand which chronic illnesses and systemic diseases can benefit from glucocorticoid use Case … Case B: Part 1 (cont.) … Case C: Part 1 (cont.) On examination he appeared ill and was mildly tachypneic.