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2501. Cognitive Overload in the ICU | PSNet
      psnet.ahrq.gov/web-mm/cognitive-overload-icu
      June 01, 2005 - SPOTLIGHT CASE Cognitive Overload in the ICU Citation Text: Patel VL, Buchman … Case Objectives Identify the role of cognitive overload—especially interruptions—in compromising … In this case, the attending physician appeared to be the lone intensivist managing nine patients. … We may be tempted to blame the physician for the errors that occurred in this case. … Sections Case Objectives Case & Commentary—Part 1: Case & Commentary—Part

2502. Which Line: Ordering Provider or Proceduralist? | PSNet
      psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
      September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? … Case Objectives Review the role of mistake-proofing to block errors from leading to adverse events … The Case A 58-year-old woman with multiple myeloma required placement of a central venous catheter … In the current case, the patient was harmed by having the incorrect catheter placed, but the error was … Sections Case Objectives The Case The Commentary Take-Home Points References

2503. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41667/psn-pdf
      September 12, 2012 - Patient safety law protects some documents in court case. September 12, 2012 Gallegos A. … https://psnet.ahrq.gov/issue/patient-safety-law-protects-some-documents-court-case This article reports … https://psnet.ahrq.gov/issue/patient-safety-law-protects-some-documents-court-case

2504. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49392/psn-pdf
      April 01, 2003 - https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized … Case & Commentary: Part 2 The patient was identified as being a fall risk. … Case & Commentary: Part 3 The patient was found on the floor with no sign of injury. … Two final thoughts occur to me as I review this case. … A case of death by physical restraint. New lessons from a photograph.

2505. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49621/psn-pdf
      March 01, 2011 - https://psnet.ahrq.gov/web-mm/volume-too-low-and-out Case Objectives Appreciate that because of multiple … The Case A 22-month-old infant was admitted to the hospital in the late afternoon with a viral infection … The Commentary   This infant's case highlights two of the major risks that hospitalized children face … In addition, this case also reveals the specific risks of dehydration in patients with congenital heart … The 2 ounces our case patient consumed on the first day of admission was only 60 mL, representing a

2506. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49480/psn-pdf
      May 01, 2005 - The case, when discussed on AHRQ WebM&M, was felt by the discussant to be a diagnostic error. … This case does not represent a missed diagnosis or a preventable error for several reasons. … In our judgment, this case is an example of the latter. … This case illustrates that missing one diagnosis may be preferred to missing another. … Three case reports. Eff Clin Pract. 2002;5:23-28. [ go to PubMed ] 9. Berlin L.

2507. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad | PSNet
      psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
      January 01, 2014 - SPOTLIGHT CASE Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad Citation … Case Objectives Understand the indications for antibiotic treatment in acute sinusitis. … A decision support system could have been very useful in this case. … A case of cascade iatrogenesis. Ann Intern Med. 2002;137:327-333. [go to PubMed] 20. … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

2508. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
      June 01, 2003 - PowerPoint Presentation Spotlight Case June 2003 Missed Appendicitis webmm.ahrq.gov Source and Credits … This presentation is based on June 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article … diagnoses List potential strategies to enhance patient safety in the emergency department (ED) Case … Case (cont.): Missed Appendicitis The next day, the patient returned to the ED with persistent pain. … She was seen by the same ED attending, who then asked a colleague to evaluate the case.

2509. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40071/psn-pdf
      December 08, 2010 - Safety shortcomings spotted in Sunrise catheter case. December 8, 2010 Harasim P. … https://psnet.ahrq.gov/issue/safety-shortcomings-spotted-sunrise-catheter-case This article discusses … https://psnet.ahrq.gov/issue/safety-shortcomings-spotted-sunrise-catheter-case

2510. Refused Medication Error | PSNet
      psnet.ahrq.gov/web-mm/refused-medication-error
      November 01, 2005 - The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status … The Commentary by Mary Foley, PhD, RN While this case is problematic on many levels, this commentary … In this case, it might even have resulted in a family member helping to improve the patient's adherence … There is no indication in this case that the EHR alerted the medical team to the abnormal findings and … Analysis of the communication breakdowns in that case included a critique of the EHR.( 10 ) As stated

2511. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44560/psn-pdf
      January 23, 2017 - With increasingly constrained hospital budgets, there has been a new focus on showing the business case … A prior AHRQ WebM&M perspective discussed strengthening the business case for patient safety. … what-return-investment-implementation-crew-resource-management-program-academic-medical https://psnet.ahrq.gov/primer/teamwork-training https://psnet.ahrq.gov/issue/making-business-case-patient-safety … https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety

2512. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36522/psn-pdf
      December 20, 2006 - A case that shook medicine. December 20, 2006 Lerner BH. … https://psnet.ahrq.gov/issue/case-shook-medicine The author reviews the legacy of Libby Zion and how … https://psnet.ahrq.gov/issue/case-shook-medicine

2513. Shake Well | PSNet
      psnet.ahrq.gov/web-mm/shake-well
      September 01, 2006 - The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder … In the second case, a pharmacy technician failed to shake thoroughly a bottle of carbamazepine suspension … In this case, failure to vigorously shake the multi-dose suspension resulted in a wrong-dose medication … For example, in a case reported to the Institute for Safe Medication Practices, 100 ml (an entire bottle … Sections The Case The Commentary References Related Resources

2514. Do Me a Favor | PSNet
      psnet.ahrq.gov/web-mm/do-me-favor
      September 12, 2016 - The Commentary This case describes a common scenario among health care professionals. … No doubt, some will read this case, scratch their heads, and wonder what the problem is, exactly. … Aside from that, what patient safety lessons are embedded in this case? … Appropriate protocols, including review of the case with another physician, were circumvented. … Ethics case study: should doctors treat their relatives? ACP Observer.

2515. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49734/psn-pdf
      May 01, 2015 - https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history … The Commentary This case represents a preventable medical error. … As documented in prior case series literature, inattention, inexperience, and inadequate supervision … Case Rep Crit Care. 2011;2011:287261. [go to PubMed] 14. … Missed central venous guide wires: a systematic analysis of published case reports.

2516. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49851/psn-pdf
      January 01, 2019 - https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history … We do not wish to evaluate the choice of lavage in this case, since no current recommendation exists … The intent was to place the patient in this case under light sedation with midazolam. … In this case, the bronchoscopy was performed in an ICU setting. … When reviewing the medical literature, we did not find any statistical overview nor any case reports

2517. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet
      psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
      February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications … That is what happened in this unfortunate case. The patient's phone number did not work. … It is determined on a case-by-case basis by unique juries deciding cases involving unique facts; therefore … Here too there are no specific rules or guidelines: the determination is made case by case. … Sections Case Objectives The Case The Commentary References Table

2518. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49655/psn-pdf
      June 01, 2012 - https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease … The case management department reviewed this case. … Moreover, the case management department felt that her nonadherence to dialysis was encouraged by the … This case is somewhat atypical, in that the patient received analgesics for recognized chronic pain. … However, this case illustrates several behaviors that are highly suspicious for addiction.

2519. All in the History | PSNet
      psnet.ahrq.gov/web-mm/all-history
      February 28, 2011 - SPOTLIGHT CASE All in the History Citation Text: Fee C. All in the History. … This case provides an opportunity to explore these critical transitions in care. … Case & Commentary: Part 2 A stat chest radiograph revealed infiltrates in the left lung. … This should be done initially and intermittently as the clinical case evolves. … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

2520. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49647/psn-pdf
      February 01, 2012 - https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip The Case A 25-year-old woman in … The laboratory in this case initially reported an incorrect value for the 24- hour urine. … As is made clear by this case, notifying the inpatient unit is often insufficient. … This case shows us that the communication must be immediate and proactive. … In this case, the diagnosis in question was preeclampsia.