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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
May 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case May 2008
Diagnosing HIV: It Doesn’t Take a Brain Surgeon … Source and Credits
This presentation is based on the May 2008
AHRQ WebM&M Spotlight Case
See … challenges associated with HIV screening practices
Review current guidelines for HIV screening
Case … Case: Diagnosing HIV (2)
The radiologist reported the findings to be concerning for a malignant rather … Case: Diagnosing HIV (3)
Upon arrival to the referral facility, the patient remained neurologically
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits … This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full … Discuss how medication reconciliation decreases the opportunity for medication errors and harm
Case … Case (cont.): Reconciling Doses
After 2 days, the patient was transitioned to Augmentin. … Case (cont.): Reconciling Doses
At the time of discharge, the patient’s INR was noted to be 4.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case September 2004
Poor Prognosis? … Source and Credits
This presentation is based on the September 2004
AHRQ WebM&M Spotlight Case in Surgery … in elderly patients
Appreciate the cognitive steps to determine prognosis in elderly patients
Case … Case (cont.): Poor Prognosis
Otorhinolaryngology (ENT) evaluation revealed no evidence of laryngeal … Case (cont.): Poor Prognosis
After further discussion, the family decided to withdraw care, because
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case June 2007
Beeline to Spine
Source and Credits
This … presentation is based on June 2007
AHRQ WebM&M Spotlight Case
See full article at http://webmm.ahrq.gov … The case against routine preoperative laboratory testing. … The case against routine preoperative laboratory testing. … The case against routine preoperative laboratory testing.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
February 01, 2010 - Spotlight Case July 2008
Spotlight Case
Adolescent Diabetes:
A Routine Visit? … Source and Credits
This presentation is based on the February 2010
AHRQ WebM&M Spotlight Case
See … Review some common errors in the care of adolescent patients and strategies to prevent them
Case … Case: Adolescent Diabetes (2)
She had presented to the clinic 18 months earlier with fatigue and polyuria … Case: Adolescent Diabetes (4)
On physical examination, she was a quiet, depressed morbidly obese girl
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - Spotlight Case July 2008
Spotlight Case
Peripheral IV in Too Long
1
2
Source and Credits
This presentation … is based on the September 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov … IVs in the hospital
State how frequently peripheral IVs should be changed in adult patients
3
4
Case … that called for all peripheral IV catheters to be replaced after 4 days to prevent infection.
4
5
Case … Arch Intern Med. 1998;158:473-477. http://www.ncbi.nlm.nih.gov/pubmed/9508225
10
Case: In Too Long
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
February 01, 2011 - Spotlight Case July 2008
Spotlight Case
One Toxic Drug Is Not Like Another
*
*
Source and Credits … This presentation is based on the February 2011
AHRQ WebM&M Spotlight Case
See the full article at … *
*
Case: One Toxic Drug
A 50-year-old man was diagnosed with chronic hepatitis C (viral load of … *
This Case: Set-up for Error
Experienced physician in a different discipline
Familiar and … company denied the hospital bill, and the medical director for case management was asked to prepare
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.92_slideshow.ppt
April 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case April 2005
Compare and Contrast
Source and Credits
This … presentation is based on the April 2005
Spotlight Case in Emergency Medicine
See the full article … pharmacologic strategies for CN prophylaxis
Follow algorithm for CN risk reduction and prevention
Case … factors, but increased to 11.2% with one risk factor and more than 20% with two risk factors.5
Case … Case (cont.): Compare and Contrast
Due to continued oliguria and persistent uremia hemodialysis was
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case May 2007
Antiseizure Medication Disorder
Source and … Credits
This presentation is based on the May 2007
AHRQ WebM&M Spotlight Case
See the full article … pharmacokinetics of phenytoin
List clinical scenarios when phenytoin levels may be unreliable
Case … Case: Antiseizure Medication Disorder
On physical exam, his vital signs were unremarkable and he had … Case: Antiseizure Medication Disorder
The rest of his electrolytes, renal function, and liver function
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia? … Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full … Case: Delirium or Dementia? (2)
At admission, the patient appeared mildly dehydrated. … Case: Delirium or Dementia? (3)
Overnight, nursing staff noted the patient to be disoriented. … Case: Delirium or Dementia?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - Spotlight Case [MONTH] 2003
Spotlight Case
Standard Deviations
Source and Credits
This presentation … is based on the December 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov … psychiatric consultations in patients whose refusal to cooperate with treatment is perplexing
Case … Understanding service disengagement from the perspective of case managers. … Understanding service disengagement from the perspective of case managers.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - Spotlight Case July 2008
Spotlight Case
The Safety and Quality of Long Term Care
*
*
Source and … Credits
This presentation is based on the September 2011
AHRQ WebM&M Spotlight Case
See the full article … in nursing homes
Describe what is being done or can be done to make nursing homes safer
*
*
Case … *
*
Case: Safety of Long Term Care (2)
During an unassisted transfer from her wheelchair to her … *
*
Case: Safety of Long Term Care (3)
A few weeks later, she continued to remain bedbound with
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation … is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov … *
*
Case: Not-So-Therapeutic Tap (2)
The second-year resident had performed 6 paracenteses as … *
*
Case: Not-So-Therapeutic Tap (4)
About 20 minutes later, the intern was called due to the … *
*
Case: Not-So-Therapeutic Tap (5)
A stat angiogram revealed a bleeding omental vessel that
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
January 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case January 2008
How Do Providers Recover from Errors? … Source and Credits
This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case
See the … including error disclosure
Review potential support structures for providers involved in errors
Case … Case: How Do Providers Recover from Errors? … Case: How Do Providers Recover from Errors?
Consent was obtained from the patient and his wife.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits … This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http … Case: Bad Writing, Wrong Medication (1)
*
*
Case: Bad Writing, Wrong Medication (2)
Shortly after … Med Care. 2005;43:1171-1176. http://www.ncbi.nlm.nih.gov/pubmed/16299427
*
Case: Bad Writing, Wrong … In This Case
This medication error was a preventable ADE and caused patient harm
System improvements
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient … Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the … Case: Wire we here? … Case (cont.): Wire we here? … Case (cont.): Wire we here?
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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
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - Spotlight Case [MONTH] 2003
Spotlight Case February 2007
The ‘Customer’ Is Always Right
Source … and Credits
This presentation is based on the February 2007
AHRQ WebM&M Spotlight Case
See the full … the relationship between patient-centered care and safety, quality, and patient satisfaction
Case … Case: The ‘Customer’ Is Always Right
Physical exam revealed a fussy child with normal vital signs and … Case: The ‘Customer’ Is Always Right
The resident advised the mom that a fracture was unlikely based
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
July 01, 2008 - Spotlight Case July 2008
Spotlight Case July 2008
Dependence vs. … Case: Dependence vs. … Available at: http://www.ncbi.nlm.nih.gov/pubmed/15204675
Issues in Present Case
In this case, … Case (cont.): Dependence vs. … Case (cont.): Dependence vs.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
May 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case May 2004
Too Tight Control:
The Risks of Intensive Insulin … Therapy
Source and Credits
This presentation is based on the May 2004
AHRQ WebM&M Spotlight Case … Understand the difference between efficacy and effectiveness with regards to results of clinical trials
Case … Infection and diabetes: the case for glucose control. … cmd=Retrieve&db=PubMed&list_uids=11242719&dopt=Abstract
Case (cont.): Too Much of a Good Thing