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401. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
     January 01, 2022 - Spotlight Spotlight A Case of Mistaken Capacity: Why a Thorough Psychosocial History Can Improve … Care Source and Credits • This presentation is based on the March 2022 AHRQ WebM&M Spotlight Case … The multidisciplinary team in palliative care: A case reflection. … of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care Case Details (1) Case Details … (2) Case Details (3) Case Details (4) Case Details (5) A Case of Mistaken Capacity: Why a Thorough

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73336/psn-pdf
     May 26, 2021 - https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  … (Editors Note: PSNet case submissions are anonymous and the submitted materials did not indicate whether … ,12 also experienced by the patient in this case. … Approach to Improving Outcomes This case represents the confluence of several troublesome issues. … Case Rep Infect Dis. 2013;2013:293823. doi:10.1155/2013/293823. Go to PubMed 13.

403. Resuscitation Errors: A Shocking Problem | PSNet
     psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
     October 19, 2022 - SPOTLIGHT CASE Resuscitation Errors: A Shocking Problem Citation Text: Edelson … Case Objectives Appreciate that delays in defibrillation can have significant negative effects on … Case & Commentary: Part 1 A middle-aged man presented to the hospital with chest pain. … To reduce avoidable errors, as occurred in this case, the Defibrillator Working Group recommended use … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72731/psn-pdf
     February 10, 2021 - in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case … in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case … intensive care unit (ICU)may be at risk for adverse events.Results from this multi-site retrospective case … lost-sign-out-and-documentation https://psnet.ahrq.gov/issue/ranking-hospitals-avoidable-death-rates-derived-retrospective-case-record-review

405. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination | PSNet
     psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
     April 29, 2020 - The Case A 71-year-old frail, non-ambulatory woman a with history of multiple sclerosis and neurogenic … series reported in the literature and as high as 88% in others 1 (although the published case series … Therefore, the rapid breathing, diarrhea, and sweating experienced by the patient in this case on the … In this case, the patient tested negative twice for SARS-CoV-2, which both clinicians and caregivers … J Surg Case Rep . 2017;2017(12):rjx239.

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50697/psn-pdf
     November 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation November 27, 2019 Kulig CE, Ebong IA … Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. 2019. … https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation The Case A 36-year-old … Ebong, MBBS, MS This case highlights how commonly prescribed medications can lead to serious adverse … The error in this case was only recognized after the patient suffered a cardiac arrest.

407. Breakage of a PICC Line | PSNet
     psnet.ahrq.gov/web-mm/breakage-picc-line
     June 21, 2023 - SPOTLIGHT CASE Breakage of a PICC Line Citation Text: Dimov V. … Case Objectives Appreciate the incidence and consequences of PICC line breakage. … Understand the treatment options in case of PICC line breakage. … According to the case reporter, after this case was reviewed, the hospital mandated that a syringe with … Sections Case Objectives The Case The Commentary References Table

408. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
     January 01, 2021 - Artifact Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case … radiologists and referring physicians can contribute to delays in diagnosis and treatment 4 Case … We’ve Got Here is a Failure to Communicate” (1) • The two principal communicating parties in this case … – However, the radiologist in this case was also implicated in the civil suit filed by the patient … Details Case Details Case Details The consequences of miscommunication regarding a possible artifact

409. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet
     psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
     October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited … PhD, RN; Patrick Romano, MD, MPH; Garth Utter, MD; and Scott Zakaluzny, MD, FACS, for this Spotlight Case … The Case A 67-year-old man, in excellent health except for seasonal allergies and mild lower urinary … In any case, leaving the bone graft site open and allowing ongoing bleeding from the site at the end … Specifically for this case involving bone, bone wax is a helpful adjunct.

410. A framework for assessing reasoning about controversial end-of-life clinical decisions. | PSNet
     psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
     November 30, 2023 - The Case A 65-year-old man with metastatic hepatocellular carcinoma (HCC), status-post partial hepatectomy … from an “order-of-reasons” problems, demonstrate how the proposed framework applies to the current case … Applicability to The Case In this case, reasons at the level of emergent patient safety concerns (PS … Finally, this is a case where there is no middle ground — no obvious reconciliation of the competing … In this case, refusal to implement the physician’s order for continuous intravenous opioid analgesia

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838251/psn-pdf
     October 05, 2022 - This case report describes a blood transfusion error and summarizes the systems issues that emerged … during the root case analysis, as well as the corrective steps implemented by the hospital to prevent … A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion … identifying-key-errors-threatening https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample https://psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional

412. Updates in the Management of High-Risk Pulmonary Embolism | PSNet
     psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
     December 02, 2020 - Case Objectives Review common risk factors, typical presentation, methods for risk stratification … Case and Commentary—Part 1 A 45-year-old man with obesity presented to the emergency department with … Case and Commentary—Part 4 The patient received a bed on the stepdown unit several hours later. … Sections Case Objectives Case and Commentary—Part 1 Case and Commentary—Part … 2 Case and Commentary—Part 3 Case and Commentary—Part 4 Take-Home Points Table References

413. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
     January 01, 2024 - Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case … Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 4 4 Case … Nurses continued to report that she was intermittently uncommunicative with a “fixed” gaze. 6 6 Case … At this point, however, the case begins to move from a complicated case to a complex one; the endoscopy … The importance of early problem representation during case presentations.

414. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
     January 01, 2020 - Diagnosis in Primary Care 1 This presentation is based on the April 2014 AHRQ WebM&M Spotlight Case … Discuss the need in primary care to have a low threshold to refer for neurologic consultation 3 Case … to the same clinic with worsening symptoms, including more frequent falls and new back pain. 4 Case … He was admitted to the hospital and underwent urgent neurosurgical decompression. 5 Case: ʺReflexiveʺ … From possible to probable to sure to wrong—premature closure and anchoring in a complicated case.

415. Intubation Mishap | PSNet
     psnet.ahrq.gov/web-mm/intubation-mishap
     April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. … Case Objectives To understand and apply a structured method of human factors case analysis To describe … Teamwork and Communication This case illustrates an unfortunately common occurrence in health care: … —In this case, the induction drugs were administered before the intubation equipment was ready. … Sections Case Objectives Case & Commentary References Tables Figure Videos

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73103/psn-pdf
     March 31, 2021 - /psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination The Case … is a rare complication of infection that is accompanied by a high mortality rate, 20- 40% in some case … series reported in the literature and as high as 88% in others1 (although the published case series … Therefore, the rapid breathing, diarrhea, and sweating experienced by the patient in this case on the … J Surg Case Rep. 2017;2017(12):rjx239. Published 2017 Dec 8. doi:10.1093/jscr/rjx239 3.

417. 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

418. 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.

419. 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

420. 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