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7421. 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

7422. 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.

7423. 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.

7424. 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.

7425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35895/psn-pdf
      August 24, 2018 - Building a case for medication reconciliation. August 24, 2018 ISMP Medication Safety Alert! … https://psnet.ahrq.gov/issue/building-case-medication-reconciliation This article presents examples … https://psnet.ahrq.gov/issue/building-case-medication-reconciliation https://psnet.ahrq.gov/primer/medication-reconciliation

7426. 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

7427. 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

7428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42866/psn-pdf
      January 22, 2014 - Patient harm: when an attorney won't take your case. January 22, 2014 Allen M; Pierce O. … https://psnet.ahrq.gov/issue/patient-harm-when-attorney-wont-take-your-case This news article includes … https://psnet.ahrq.gov/issue/patient-harm-when-attorney-wont-take-your-case https://psnet.ahrq.gov/issue

7429. 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

7430. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
      June 01, 2003 - PowerPoint Presentation Spotlight Case June 2003 Missed Appendicitis webmm.ahrq.gov Source and Credits … This presentation is based on June 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article … diagnoses List potential strategies to enhance patient safety in the emergency department (ED) Case … Case (cont.): Missed Appendicitis The next day, the patient returned to the ED with persistent pain. … She was seen by the same ED attending, who then asked a colleague to evaluate the case.

7431. 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

7432. 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

7433. 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.

7434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49480/psn-pdf
      May 01, 2005 - The case, when discussed on AHRQ WebM&M, was felt by the discussant to be a diagnostic error. … 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.

7435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38979/psn-pdf
      October 14, 2009 - The case of resident physicians' medical errors. … https://psnet.ahrq.gov/issue/active-learning-when-more-better-case-resident-physicians-medical-errors … https://psnet.ahrq.gov/issue/active-learning-when-more-better-case-resident-physicians-medical-errors

7436. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42606/psn-pdf
      September 25, 2013 - health-economic-evaluation-infection-prevention-and-control-program-are- quality-and-patient Safety professionals are still striving to establish the business case … Health care–associated infections (HAIs) are one area where demonstrating the business case should be … Although these findings support the business case for safety at the system level, other studies have … health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient https://psnet.ahrq.gov/issue/making-business-case-patient-safety

7437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42590/psn-pdf
      August 02, 2015 - determining costs used in the original studies, other studies have shown a relatively strong business case … comparative-economic-analyses-patient-safety-improvement-strategies-acute-care-systematic https://psnet.ahrq.gov/issue/business-case-quality-economic-analysis-michigan-keystone-patient-safety-program-icus … https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis

7438. Refused Medication Error | PSNet
      psnet.ahrq.gov/web-mm/refused-medication-error
      November 01, 2005 - The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status … The Commentary by Mary Foley, PhD, RN While this case is problematic on many levels, this commentary … In this case, it might even have resulted in a family member helping to improve the patient's adherence … There is no indication in this case that the EHR alerted the medical team to the abnormal findings and … Analysis of the communication breakdowns in that case included a critique of the EHR.( 10 ) As stated

7439. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad | PSNet
      psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
      January 01, 2014 - SPOTLIGHT CASE Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad Citation … Case Objectives Understand the indications for antibiotic treatment in acute sinusitis. … A decision support system could have been very useful in this case. … A case of cascade iatrogenesis. Ann Intern Med. 2002;137:327-333. [go to PubMed] 20. … Sections Case Objectives Case & Commentary: Part 1 Case & Commentary: Part 2

7440. Shake Well | PSNet
      psnet.ahrq.gov/web-mm/shake-well
      September 01, 2006 - The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder … In the second case, a pharmacy technician failed to shake thoroughly a bottle of carbamazepine suspension … In this case, failure to vigorously shake the multi-dose suspension resulted in a wrong-dose medication … For example, in a case reported to the Institute for Safe Medication Practices, 100 ml (an entire bottle … Sections The Case The Commentary References Related Resources