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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45055/psn-pdf
     December 04, 2016 - Analysis of clinical decision support system malfunctions: a case series and survey. … Analysis of clinical decision support system malfunctions: a case series and survey. … https://psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey … https://psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey

462. Amended Lab Results: Communication Slip | PSNet
     psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
     September 26, 2012 - The Case A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset … The laboratory in this case initially reported an incorrect value for the 24-hour urine. … As is made clear by this case, notifying the inpatient unit is often insufficient. … This case shows us that the communication must be immediate and proactive. … In this case, the diagnosis in question was preeclampsia.

463. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
     psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
     April 09, 2014 - SPOTLIGHT CASE The Hazards of Distraction: Ticking All the EHR Boxes Citation Text … Case Objectives List the goals of having order sets in the electronic health record. … The Case A 55-year-old woman with a history of metastatic cancer of unknown origin was sent to the … contraindicated) items are clearly, prompting users to consider whether these optional items are necessary on a case-by-case … Sections Case Objectives The Case The Commentary Take-Home Points References

464. The Missing Abscess: Radiology Reads in the Digital Era | PSNet
     psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
     January 01, 2009 - SPOTLIGHT CASE The Missing Abscess: Radiology Reads in the Digital Era Citation … Case Objectives Identify the most common complication of hysterectomy. … function associated with elective oophorectomy.( 3 ) It is important to approach this decision on a case-by-case … The Case In this case, the radiologist probably didn't know the history that the ovaries were not removed … Sections Case Objectives The Case The Commentary Take-Home Points References

465. Peripheral IV in Too Long | PSNet
     psnet.ahrq.gov/web-mm/peripheral-iv-too-long
     September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. … This case provides one example of the hazards of this seemingly benign medical device. … What should be learned from this case and what should be changed? … In this case, there were multiple issues with the IV management. … Sections Case Objectives Case & Commentary—Part 1: Case & Commentary—Part

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49423/psn-pdf
     November 01, 2003 - https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained … Case & Commentary: Part 1 A 65-year-old, 124-kg man with aortic stenosis and coronary artery disease … The patient’s surgery, scheduled as the second case of the day, began in mid-afternoon. … What went wrong in this case? … , along with provider fatigue (since it was an afternoon case).

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40260/psn-pdf
     February 08, 2017 - A case for safety leadership team training of hospital managers. … A case for safety leadership team training of hospital managers. … https://psnet.ahrq.gov/issue/case-safety-leadership-team-training-hospital-managers Active and engaged … https://psnet.ahrq.gov/issue/case-safety-leadership-team-training-hospital-managers https://psnet.ahrq.gov

468. Near Miss with Bedside Medications | PSNet
     psnet.ahrq.gov/web-mm/near-miss-bedside-medications
     February 01, 2006 - SPOTLIGHT CASE Near Miss with Bedside Medications Citation Text: Wu AW. … This case can be defined as a near miss. … In the case of errors that go unnoticed, there is no attempt at recovery. … How should this case be handled in an ideal world? … Sections Case Objectives The Case The Commentary References Figures

469. 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.

470. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
     October 01, 2015 - Patient With a Known Allergy 1 This presentation is based on the October 2015 AHRQ WebM&M Spotlight Case … interoperability List barriers to rapid and seamless transmission of usable patient care data 3 Case … with sepsis and had received antibiotics and IV fluids for presumed infection prior to leaving. 4 Case … resuscitation, spontaneous circulation returned, and he was intubated and transferred to the ICU. 5 Case … This severe life-threatening allergic reaction was not known to any providers at Hospital Y. 7 Case

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49654/psn-pdf
     June 01, 2012 - https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients … The Case An orthopedic surgeon at a small community hospital contacted an emergency department (ED) … They had taken her to the operating room, but she developed low blood pressure before the case and the … The surgical team proceeded, but the case was complicated by significant hemodynamic instability. … In this case, no documentation was transported with the patient.

472. 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.

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49472/psn-pdf
     March 01, 2005 - https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed … Just as important, given a potentially transmissible disease, the case provides an opportunity to examine … for syphilis, gonorrhea (urethral, rectal, and pharyngeal), and chlamydia.(8) The clinician in this case … In the "Lost in the Black Hole" case presented in this journal (9), Wachter underscored the importance … Health Department Reporting This case also involves a reportable disease, and therefore demonstrates

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41667/psn-pdf
     September 12, 2012 - Patient safety law protects some documents in court case. September 12, 2012 Gallegos A. … https://psnet.ahrq.gov/issue/patient-safety-law-protects-some-documents-court-case This article reports … https://psnet.ahrq.gov/issue/patient-safety-law-protects-some-documents-court-case

475. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
     May 01, 2017 - Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case … approaches for individual physicians and health care organizations to address diagnostic error 3 Case … right upper quadrant tenderness on examination, but the exam was limited because of his obesity. 4 Case … patient had progressively severe pain, requiring relatively high doses of intravenous morphine. 5 Case … was attributed to the patient's obesity, and he was given a small bolus of intravenous fluids. 7 Case

476. 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

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40071/psn-pdf
     December 08, 2010 - Safety shortcomings spotted in Sunrise catheter case. December 8, 2010 Harasim P. … https://psnet.ahrq.gov/issue/safety-shortcomings-spotted-sunrise-catheter-case This article discusses … https://psnet.ahrq.gov/issue/safety-shortcomings-spotted-sunrise-catheter-case

478. 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

479. 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.

480. 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