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421. 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

422. 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?

423. Feeling No Pain | PSNet
     psnet.ahrq.gov/web-mm/feeling-no-pain
     August 30, 2023 - The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. … most likely would be considered errors of omission by the individual nurses, rather than allowing a case … Consideration of the basic care-providing systems in this case provides useful insights. … Because this analysis was limited to the material in the case report, it is less comprehensive than it … Sections The Case The Commentary References Figure Related

424. One Bronchoscopy, Two Errors | PSNet
     psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
     December 09, 2020 - The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit ( … 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

425. Hard to Swallow | PSNet
     psnet.ahrq.gov/web-mm/hard-swallow
     April 26, 2023 - The Case An elderly man underwent hernia surgery. … This particular case was reviewed within an hour of the patient's death. … The problem, as illustrated in this case, is that sometimes information in the medical record is not … Finally, let's consider some of the specifics of this case. … The hospital where this case occurred has suggested an organizational solution to the problem.

426. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet
     psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
     September 25, 2019 - SPOTLIGHT CASE Managing Complexity in Diagnosis: Life-threatening Complications after Gastric … The Case About five weeks after gastric bypass surgery, a woman began experiencing nausea and vomiting … At this point, however, the case begins to move from a complicated case to a complex one; the endoscopy … In this case, the patient developed new problems superimposed on old ones throughout the case, adding … The importance of early problem representation during case presentations.

427. Diagnosing Diagnostic Mistakes | PSNet
     psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
     April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams … 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.

428. Transfer Troubles | PSNet
     psnet.ahrq.gov/web-mm/transfer-troubles
     December 29, 2014 - SPOTLIGHT CASE Transfer Troubles Citation Text: Hains IM. Transfer Troubles. … Case Objectives Recognize that transfer of patients between hospitals is common. … The surgical team proceeded, but the case was complicated by significant hemodynamic instability. … In this case, no documentation was transported with the patient. … Sections Case Objectives The Case The Commentary References Table

429. Code Status Confusion | PSNet
     psnet.ahrq.gov/web-mm/code-status-confusion
     September 01, 2006 - SPOTLIGHT CASE Code Status Confusion Citation Text: Lo B, Tulsky JA. … In this case, the patient was asked, “Would you want your life prolonged?” … One should not over-generalize from this unusual case. … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2 … Case & Commentary: Part 3 Case & Commentary: Part 4 References Related Resources

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45219/psn-pdf
     November 21, 2016 - Patient and Family Engagement in Primary Care: Case Studies. … https://psnet.ahrq.gov/issue/patient-and-family-engagement-primary-care-case-studies Patient safety … This guide includes case studies that explore how Open Notes, team-based care delivery, and patient … https://psnet.ahrq.gov/issue/patient-and-family-engagement-primary-care-case-studies https://psnet.ahrq.gov

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47260/psn-pdf
     August 08, 2018 - Building the Case for Health Literacy: Proceedings of a Workshop. … https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop Health literacy affects … This workshop report summarizes discussions about health literacy programs and provides case studies … https://psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop https://psnet.ahrq.gov

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46326/psn-pdf
     October 18, 2017 - Surgical Patient Safety: A Case-Based Approach. October 18, 2017 Stahel PF, ed. … https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach Surgical residency can be a … textbook provides an introduction to nontechnical aspects of safe surgical practice, a collection of case … https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach https://psnet.ahrq.gov/issue

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43882/psn-pdf
     February 18, 2015 - Case Studies in Patient Safety: Foundations for Core Competencies. … https://psnet.ahrq.gov/issue/case-studies-patient-safety-foundations-core-competencies Patient stories … medical errors with further information from the editors including context, learning objectives, and a case … https://psnet.ahrq.gov/issue/case-studies-patient-safety-foundations-core-competencies https://psnet.ahrq.gov

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43639/psn-pdf
     October 29, 2014 - Ebola case raises concern about everyday hospital safety. October 29, 2014 Rodricks D. … https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety Although significant … https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety https://psnet.ahrq.gov … /issue/dallas-ebola-case-shows-even-sound-plans-can-fail-spectacularly https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis-prospective-database

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35106/psn-pdf
     April 06, 2011 - A case of the birth and death of a high reliability healthcare organisation. … A case of the birth and death of a high reliability healthcare organisation. … https://psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-healthcare-organisation This commentary … https://psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-healthcare-organisation https://psnet.ahrq.gov

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43708/psn-pdf
     May 28, 2015 - The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health … The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health … https://psnet.ahrq.gov/issue/impact-time-work-and-time-work-rule-compliance-case-hand-hygiene-health- … https://psnet.ahrq.gov/issue/impact-time-work-and-time-work-rule-compliance-case-hand-hygiene-health-care … https://psnet.ahrq.gov/issue/impact-time-work-and-time-work-rule-compliance-case-hand-hygiene-health-care

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45257/psn-pdf
     July 27, 2016 - Exploring approaches to patient safety: the case of spinal manipulation therapy. … Exploring approaches to patient safety: the case of spinal manipulation therapy. … https://psnet.ahrq.gov/issue/exploring-approaches-patient-safety-case-spinal-manipulation-therapy This … https://psnet.ahrq.gov/issue/exploring-approaches-patient-safety-case-spinal-manipulation-therapy https

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44002/psn-pdf
     March 25, 2015 - Preventing medication errors in transitions of care: a patient case approach. … Preventing medication errors in transitions of care: A patient case approach. … https://psnet.ahrq.gov/issue/preventing-medication-errors-transitions-care-patient-case-approach Transitions … https://psnet.ahrq.gov/issue/preventing-medication-errors-transitions-care-patient-case-approach https

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41249/psn-pdf
     December 21, 2014 - Physicians' needs in coping with emotional stressors: the case for peer support. … Physicians' needs in coping with emotional stressors: the case for peer support. … https://psnet.ahrq.gov/issue/physicians-needs-coping-emotional-stressors-case-peer-support This study … https://psnet.ahrq.gov/issue/physicians-needs-coping-emotional-stressors-case-peer-support https://psnet.ahrq.gov

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45640/psn-pdf
     September 01, 2018 - Case outcomes in a communication-and-resolution program in New York hospitals. … Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. … https://psnet.ahrq.gov/issue/case-outcomes-communication-and-resolution-program-new-york-hospitals Communication-and-resolution … https://psnet.ahrq.gov/issue/case-outcomes-communication-and-resolution-program-new-york-hospitals https