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1. Submit Case | PSNet
   psnet.ahrq.gov/submit-case-landing
   April 24, 2024 - Case Submission Benefits Case Selection Criteria Who Can Submit a Case? … case. … a commentary based on the case. … Submit Your Case Please select your preferred way to submit a case. … Submit Your Case Please select your preferred way to submit a case.

2. WebM&M: Case Studies | PSNet
   psnet.ahrq.gov/webmm-case-studies
   April 24, 2024 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical … Submit your case below to help the medical community and to prevent similar errors in the future. … Submit Your Case This Month's WebM&Ms Update Date: April 10 … , 2024 Spotlight Case CE/MOC New Missed Connection: A … Submit Your Case All WebM&M: Case Studies (645)

3. The Submit a Case Process | PSNet
   psnet.ahrq.gov/submit-case
   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. A Sweet Case of Hidden Hydrogen Ions | PSNet
   psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
   November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions Save Save to your library Print … The Case  A 24-year-old, Arabic-speaking woman with a history of type 1 diabetes mellitus, gastroparesis … The Commentary  By Deborah Plante, MD, and Andrea Gonzalez Falero, MD  This case presents two of … The diagnosis may have been further delayed in this case due to the patient being Arabic-speaking, and … Step 2: Calculate anion gap (AG = Na-(Cl+HCO3) = 137-(96+18) = 23 in this case).

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.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. 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.

8. Diagnostic Errors Case Studies | PSNet
   psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
   February 08, 2023 - The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case … Through the PRIDE Learning Network, diagnostic error case studies were reviewed to identify common pitfalls … These de-identified case studies are free to view and available through this Curated Library. … In this case, a mixture of... … Read More Spotlight Case Anemia and Delayed Colon Cancer Diagnosis

9. Case studies on medication reconciliation. | PSNet
   psnet.ahrq.gov/issue/case-studies-medication-reconciliation
   February 15, 2023 - Special or Theme Issue Case studies on medication reconciliation. … The journal provides an editorial and several case studies on medication reconciliation from a variety … September 13, 2023 TQIP Mortality Reporting System Case Reports.

10. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation | PSNet
    psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
    March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation Save Save to your library … The Case A 36-year-old woman with a history of depression, bipolar disorder and a recent manic episode … Ebong, MBBS, MS This case highlights how commonly prescribed medications can lead to serious adverse … Approach to Improving Safety Many of the medications involved in this case, such as ondansetron and … The error in this case was only recognized after the patient suffered a cardiac arrest.

11. Continuous Improvement of Patient Safety: The Case for Change in the NHS. | PSNet
    psnet.ahrq.gov/issue/continuous-improvement-patient-safety-case-change-nhs
    December 20, 2023 - Book/Report Continuous Improvement of Patient Safety: The Case for Change in the

12. Submit a Case | PSNet
    psnet.ahrq.gov/Webmm/submit-case
    February 26, 2021 - Submit a Case Health care professionals may submit de-identified cases to AHRQ … When a case is selected, WebM&M editors invite an expert author to write a commentary based on the … case. … your case to another site, please do so independent of your submission to AHRQ WebM&M. … Verify Email Submit Case

13. Submit a Case | PSNet
    psnet.ahrq.gov/webmm/submit-case
    February 12, 2021 - Submit a Case Breadcrumb Submit a Case Case Form The … content of case submissions is anonymous. … 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.

14. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
    December 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case December 2007 Elopement Source and Credits This presentation … is based on the December 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … Case: Elopement On the morning of anticipated discharge, the patient was not in his room at the time … Case (cont.): Elopement Ultimately, the patient was found outside the emergency department, with ED … Case (cont.): Elopement Even though the ED staff had noted the patient to be mildly confused, in the

15. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research … Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case … plans Appreciate system capacities for covering sudden changes and overload situations * * Case … Case: Nurse Staffing Ratios (2) The nurse implemented the initial orders as the patient was stabilized … He began to transition to intermittent, rather than continuous, nebulizer treatments. * * Case:

16. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
    December 01, 2012 - Spotlight Case July 2008 Spotlight Case The Lung Nodule That Refused To Grow * * Source and Credits … This presentation is based on the December 2012 AHRQ WebM&M Spotlight Case See the full article at … benign disease Understand when patients no longer need surveillance for benign disease * * Case … * Case: Lung Nodule (2) Upon further history, the patient stated that while undergoing a hernia … * Case: Lung Nodule (3) The patient had a 6-month follow-up CT scan in 2004 confirming the nodule

17. 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

18. 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

19. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
    October 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case October 2004 Thin Air Source and Credits This presentation … is based on the Oct. 2004 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov … in human procedures Review strategies to prevent delivery of wrong gas to hospitalized patients Case … Case (cont.): Thin Air The patient was intubated for hypoxemic respiratory failure. … through them and notice that the outflow ports are different. 14.bin What Went Wrong in This Case

20. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - Spotlight Case July 2008 Spotlight Case Watch the Warfarin! … 1 2 Source and Credits This presentation is based on the July 2011 AHRQ WebM&M Spotlight Case See the … in the safe management of warfarin Recognize the risks and benefits of newer anticoagulants 3 4 Case … for his atrial fibrillation, and this medication was continued while he was in the hospital. 4 5 Case … to any of the medications he was taking before the hospitalization, including the warfarin. 5 6 Case