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2561. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
      January 01, 2022 - Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case … ASSUMPTIONS RESULT IN A MISSED PNEUMOTHORAX AFTER BRONCHOSCOPY WITH TRANSBRONCHIAL BIOPSY This case … the complications associated with bronchoscopy and strategies to improve perioperative safety 4 Case … • The patient recovered without change in respiratory symptoms or vital signs in the PACU. 5 Case … Details (1) Case Details (2) Case Details (3) Case Details (4) False Assumptions Result in a Missed

2562. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
      January 01, 2020 - Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case … Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case … OF INPATIENT CARDIAC ARREST A case describing serious and preventable complications – cardiac arrest … a consult from Orthopedics • Managed with antibiotics, subcutaneous insulin, and IV fluids 5 Case … hospital one week later with implanted cardioverter-defibrillator 7 WHEN THE LYTES GO OUT: A CASE

2563. Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
      January 01, 2021 - Embolism Source and Credits • This presentation is based on the February 2021 AHRQ WebM&M Spotlight Case … information led to missed diagnosis of submassive pulmonary embolism resulting in fatality 4 Case … on chest radiograph • Patient was admitted to the hospital for acute asthma exacerbation 5 Case … Case Reports in Orthopedics. 2013;2013(3):1-3. doi:10.1155/2013/401968. 5. … Pulmonary Embolism and Severe Asthma: Case Report and Literature Review.

2564. An Outpatient 'Zebra' | PSNet
      psnet.ahrq.gov/web-mm/outpatient-zebra
      January 23, 2020 - The Case A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain … The fact that attending physicians supervise residents, as occurred in this case, puts this argument … A second important issue is continuity of care or, in this case, a lack of continuity. … The resident first sees the patient and then presents the case to the attending physician. … case scenarios?

2565. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - SPOTLIGHT CASE Premature Closure: Was It Just Syncope? … Romano, Bakerjian, Barnes, Maurier, and Shaikh (author(s) and reviewers) for this Spotlight Case and … as checklists and forcing functions to mitigate cognitive biases and prevent adverse events The Case … As an alternative to admission, the physician discussed the case with a cardiologist who recommended … This commentary will discuss the specific errors highlighted by this case and identify individual and

2566. Recurrent Hypoglycemia: A Care Transition Failure? | PSNet
      psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
      December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? … Case Objectives Understand the complementary abilities of an electronic health record and a personal … The challenge of health literacy immediately presents itself at this point in the case. … The case report does not mention whether the patient's primary care physician received communication … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

2567. A Painful Dilemma | PSNet
      psnet.ahrq.gov/web-mm/painful-dilemma
      September 01, 2013 - The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted … 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.

2568. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency … 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.

2569. 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

2570. 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.

2571. 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

2572. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42606/psn-pdf
      September 25, 2013 - health-economic-evaluation-infection-prevention-and-control-program-are- quality-and-patient Safety professionals are still striving to establish the business case … Health care–associated infections (HAIs) are one area where demonstrating the business case should be … Although these findings support the business case for safety at the system level, other studies have … health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient https://psnet.ahrq.gov/issue/making-business-case-patient-safety

2573. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42590/psn-pdf
      August 02, 2015 - determining costs used in the original studies, other studies have shown a relatively strong business case … comparative-economic-analyses-patient-safety-improvement-strategies-acute-care-systematic https://psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus … https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis

2574. 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

2575. 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.

2576. 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.

2577. 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

2578. 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

2579. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47262/psn-pdf
      August 22, 2018 - The Case for Medication Safety Officers (MSO). … https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso Medication safety is a concern in various … https://psnet.ahrq.gov/issue/case-medication-safety-officers-mso https://psnet.ahrq.gov/issue/medication-safety-officers-handbook

2580. 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