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441. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34697/psn-pdf
     December 08, 2010 - In memory of Ben—a case study. December 8, 2010 Haas D. Sentinel events. … In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5. … https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study Written from the perspective of a … https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study https://psnet.ahrq.gov/issue/beyond-blame-solutions-americas-other-drug-problem-dvd

442. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35809/psn-pdf
     February 25, 2015 - Stories from the sharp end: case studies in safety improvement. … Milbank Q. 2006;84(1):165-200 https://psnet.ahrq.gov/issue/stories-sharp-end-case-studies-safety-improvement … definitions, attributes, and strategies to approach the issue, and present a detailed account of each case … https://psnet.ahrq.gov/issue/stories-sharp-end-case-studies-safety-improvement https://psnet.ahrq.gov

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46693/psn-pdf
     December 20, 2017 - Coupling policymaking with evaluation—the case of the opioid crisis. … Coupling Policymaking with Evaluation - The Case of the Opioid Crisis. … https://psnet.ahrq.gov/issue/coupling-policymaking-evaluation-case-opioid-crisis Policy solutions are … https://psnet.ahrq.gov/issue/coupling-policymaking-evaluation-case-opioid-crisis https://psnet.ahrq.gov

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47298/psn-pdf
     September 24, 2018 - Physician engagement in malpractice risk reduction: a UPHS case study. … Physician Engagement in Malpractice Risk Reduction: A UPHS Case Study. … https://psnet.ahrq.gov/issue/physician-engagement-malpractice-risk-reduction-uphs-case-study Physician … https://psnet.ahrq.gov/issue/physician-engagement-malpractice-risk-reduction-uphs-case-study https://

445. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
     February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is … based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … medication-use system Select effective risk-reduction strategies to prevent medication errors 3 Case … Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. … id=51 20 This Case This case highlights the multiple systems failures.

446. Who Nose Where the Airway Is? | PSNet
     psnet.ahrq.gov/web-mm/who-nose-where-airway
     May 01, 2016 - Because the surgery was expected to involve only the arm, the case was started using local anesthesia … This case highlights two aspects that complicate the situation. … Case report—an iatrogenic foreign body in the airway. Int J Surg. 2008;6:e46-e47. … Aspiration of a nasal airway: a case report and principles of management. … Airway within airway: a case report. Indian J Anaesth. 2004;48:486-487. [Available at] 4.

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49622/psn-pdf
     March 01, 2011 - https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr The Case A patient followed at a … Although the case refers to the incident as an error, it is not clear that the events in the case meet … Or as in this case, it may simply be that the patient catches the problem before harm occurs. … The clinic in the case could have averted this situation. … In this case, a "what if?" analysis would have sufficed.

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47673/psn-pdf
     January 09, 2019 - disrupting-diagnostic-reasoning-do-interruptions-instructions-and-experience-affect https://psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice … https://psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34667/psn-pdf
     January 17, 2018 - Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. … https://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond- blaming-individuals … https://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals … https://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals

450. Preventable Rash | PSNet
     psnet.ahrq.gov/web-mm/preventable-rash
     October 01, 2012 - The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. … The Commentary This case highlights the danger of inadequate follow-up of outpatient tests and the … Just as important, given a potentially transmissible disease, the case provides an opportunity to examine … routinely obtained ( 1,2 ), and few providers have obtained adequate training.( 3 ) Second, this case … Health Department Reporting This case also involves a reportable disease, and therefore demonstrates

451. Volume Too Low: In and Out | PSNet
     psnet.ahrq.gov/web-mm/volume-too-low-and-out
     July 01, 2017 - SPOTLIGHT CASE Volume Too Low: In and Out Citation Text: Miller MR. … Case Objectives Appreciate that because of multiple factors, children are at high risk for medical … The Commentary   This infant's case highlights two of the major risks that hospitalized children … How could the errors in this case have been prevented? … Sections Case Objectives The Case The Commentary References Figure

452. Dropping the Ball Despite an Integrated EMR | PSNet
     psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
     January 07, 2015 - The Case A patient followed at a community-based clinic that is part of a large health care system … Although the case refers to the incident as an error, it is not clear that the events in the case meet … Or as in this case, it may simply be that the patient catches the problem before harm occurs. … The clinic in the case could have averted this situation. … In this case, a "what if?" analysis would have sufficed.

453. Palliative Care: Comfort vs. Harm | PSNet
     psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
     December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. … Case Objectives Recognize errors may be difficult to identify in palliative care. … The Case An 83-year-old man with chronic kidney disease and end-stage congestive heart failure (CHF … In the present case, it was reasonable to withdraw the statin, beta-blocker, and diuretic. … Sections Case Objectives The Case The Commentary References

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49593/psn-pdf
     October 01, 2009 - https://psnet.ahrq.gov/web-mm/who-nose-where-airway The Case A 70-year-old man with peripheral vascular … Because the surgery was expected to involve only the arm, the case was started using local anesthesia … This case highlights two aspects that complicate the situation. … Case report—an iatrogenic foreign body in the airway. Int J Surg. 2008;6:e46-e47. … Aspiration of a nasal airway: a case report and principles of management.

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35647/psn-pdf
     June 25, 2010 - Nurse staffing in hospitals: is there a business case for quality? … Nurse staffing in hospitals: is there a business case for quality? … https://psnet.ahrq.gov/issue/nurse-staffing-hospitals-there-business-case-quality The relationship between … https://psnet.ahrq.gov/issue/nurse-staffing-hospitals-there-business-case-quality https://psnet.ahrq.gov

456. Crushing Chest Pain: A Missed Opportunity | PSNet
     psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
     February 01, 2007 - SPOTLIGHT CASE Crushing Chest Pain: A Missed Opportunity Citation Text: Graber … What led to the fatal diagnostic error in this case? … Clinicians should routinely generate a complete differential diagnosis in every case. … "( 2 ) It is always appropriate in ED settings to rule out the "worst case scenario." … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49594/psn-pdf
     December 01, 2009 - https://psnet.ahrq.gov/web-mm/standard-deviations Case Objectives Understand the safety risks associated … Case & Commentary: Part 1   A 45-year-old man with an active history of intravenous (IV) drug use was … "(3) In this case, the hospital team provided excellent diagnosis and treatment planning. … It is common for clinicians to see a patient like the man in this case as an extreme "other." … Understanding service disengagement from the perspective of case managers.

458. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
     February 01, 2003 - PowerPoint Presentation Spotlight Case February 2003 Apnea in a Patient Under General Anesthesia webmm.ahrq.gov … Source and Credits This presentation is based on February 2003 Surgery–Anesthesia Spotlight Case … See full case–commentary on webmm.ahrq.gov CME credit is available online Commentary by: Paul Barach … , MD, MPH; University of Chicago Editor, AHRQ WebM&M: Robert Wachter, MD Spotlight Case Editor: Tracy … Case (cont.): Unexplained Apnea Before the first incision, 50 mcg of Fentanyl was administered.

459. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
     July 01, 2003 - PowerPoint Presentation Spotlight Case July 2003 Code Status Confusion webmm.ahrq.gov Source … and Credits This presentation is based on the July 2003 AHRQ WebM&M Spotlight Case See the full article … Annals of Internal Medicine. 1997; 127:1-12 Case (cont.): Code Status Confusion Upon admission, the … J Gen Intern Med. 1998;13:447-454 Case (cont.): Code Status Confusion A few hours after admission … Case (cont.): Code Status Confusion The resident had discussed the case briefly with the intern (including

460. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
     February 01, 2017 - Boxes * Source and Credits This presentation is based on the February 2017 AHRQ WebM&M Spotlight Case … consideration of clinical issues List key principles in the optimal design of order sets * * Case … The patient was admitted to a hospitalist service for observation. * Case: Ticking All the EHR Boxes … The hospital medicine service routinely reviewed all deaths on their service. * * Case: Ticking … are clearly delineated, prompting users to consider whether these optional items are necessary on a case-by-case