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81. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
    January 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case January 2004 Crushing Chest Pain: A Missed Opportunity … Source and Credits This presentation is based on the Jan. 2004 AHRQ WebM&M Spotlight Case See … limitations of heuristic thinking List the cardinal dimensions of clinical decision-making Case … Case (cont.): Crushing Chest Pain The patient was admitted to the cardiac care unit. … This Case Approached Using Heuristics Clinician knows: Acute Coronary Syndrome is the most common

82. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
    July 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case July 2005 Impatient Inpatient Dosing Source and Credits … This presentation is based on the July 2005 AHRQ WebM&M Spotlight Case in Medicine See the full … for initial dosing of warfarin Access resources available to aid providers in warfarin dosing Case … INR on Day 2 is less than 1.1 twenty or more hours after the first dose, 10 mg can be given Case … 2.32, then stop the LMWH and reduce warfarin dose to 3 or 4 mg, testing INR every few days Case

83. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
    January 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case January 2006 An Ounce of Prevention Source and Credits … This presentation is based on the Jan. 2006 AHRQ WebM&M Spotlight Case See the full article at http … extended-duration prophylaxis Appreciate interventions that may increase system-wide use of VTE prophylaxis Case … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=959958 Case (cont.): An Ounce of Prevention Review … 9459643 CT Scan in a Patient with IVC Filter Thrombosis, Causing 50% Obstruction of the IVC Case

84. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits … This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the … when caring for obese patients Develop a rational approach to medication dosing in obese patients Case … Case (cont.): The Hidden Mystery Empiric broad-spectrum antibiotics were started. … Not a hard and fast rule Case (cont.): The Hidden Mystery Six days later, the patient developed

85. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits … This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the … when caring for obese patients Develop a rational approach to medication dosing in obese patients Case … Case (cont.): The Hidden Mystery Empiric broad-spectrum antibiotics were started. … Not a hard and fast rule Case (cont.): The Hidden Mystery Six days later, the patient developed

86. Pediatric medical errors part 1: the case. A pediatric drug overdose case. | PSNet
    psnet.ahrq.gov/issue/pediatric-medical-errors-part-1-case-pediatric-drug-overdose-case
    April 22, 2020 - Study Pediatric medical errors part 1: the case. … A pediatric drug overdose case. Citation Text: Dowdell EB. … Pediatric medical errors part 1: the case. A pediatric drug overdose case. … Pediatric medical errors part 1: the case. A pediatric drug overdose case. … October 12, 2022 Organizational ambidexterity and the hybrid middle manager: the case

87. Case studies on medication reconciliation. | PSNet
    psnet.ahrq.gov/issue/case-studies-medication-reconciliation
    February 15, 2023 - Special or Theme Issue Case studies on medication reconciliation. … Citation Text: Case studies on medication reconciliation. Crawford AG; Sciamanna CN. … The journal provides an editorial and several case studies on medication reconciliation from a variety … Linkedin Copy URL Cite Citation Citation Text: Case

88. Diagnostic Errors Case Studies | PSNet
    psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
    August 10, 2025 - The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case … Through the PRIDE Learning Network, diagnostic error case studies were reviewed to identify common pitfalls … These de-identified case studies are free to view and available through this Curated Library. … In this case, a mixture of... … Schiff, MD | December 14, 2022 This case describes a man in his 70s

89. Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture/laceration. | PSNet
    psnet.ahrq.gov/issue/triangulating-case-finding-tools-patient-safety-surveillance-cross-sectional-case-study
    February 08, 2012 - Study Triangulating case-finding tools for patient safety surveillance: a cross-sectional … case study of puncture/laceration. … Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture … This study found that four existing case detection tools, including the AHRQ Patient Safety Indicators … Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture

90. WebM&M: Case Studies | PSNet
    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical … Submit your case below to help the medical community and to prevent similar errors in the future. … Submit Your Case This Month's WebM&Ms Update Date: March 25 … Submit your case below to help the medical community and to prevent similar errors in the future. … Submit Your Case All WebM&M: Case Studies (668)

91. TQIP Mortality Reporting System Case Reports. | PSNet
    psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
    March 23, 2022 - Special or Theme Issue TQIP Mortality Reporting System Case Reports. … Citation Text: TQIP Mortality Reporting System Case Reports. … Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pinpoint … This case series shares analysis of adverse events submitted to a trauma center-focused reporting program … Cite Citation Citation Text: TQIP Mortality Reporting System Case

92. AHRQ Impact Case Studies: Patient Safety. | PSNet
    psnet.ahrq.gov/issue/ahrq-impact-case-studies-patient-safety
    October 23, 2019 - Multi-use Website AHRQ Impact Case Studies: Patient Safety. … Citation Text: AHRQ Impact Case Studies: Patient Safety. … This collection of case studies highlights AHRQ-funded patient safety tools, including the Comprehensive … Copy URL Cite Citation Citation Text: AHRQ Impact Case

93. The business case for patient safety. | PSNet
    psnet.ahrq.gov/issue/business-case-patient-safety
    September 28, 2010 - Review The business case for patient safety. … The business case for patient safety. Clin Orthop Relat Res. 2007;457:21-34. … The business case for patient safety. Clin Orthop Relat Res. 2007;457:21-34. … A case study from a large metropolitan healthcare trust. … May 3, 2016 Making the business case for quality and safety.

94. A case that shook medicine. | PSNet
    psnet.ahrq.gov/issue/case-shook-medicine
    October 24, 2012 - Newspaper/Magazine Article A case that shook medicine. … Citation Text: A case that shook medicine. Lerner BH. … Linkedin Copy URL Cite Citation Citation Text: A case

95. The Case of Mistaken Intubation | PSNet
    psnet.ahrq.gov/web-mm/case-mistaken-intubation
    July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. … The Case of Mistaken Intubation. PSNet [internet]. … The Case of Mistaken Intubation. PSNet [internet]. … The Case of Mistaken Intubation. PSNet [internet]. … Sections Case Objectives The Case The Commentary References

96. Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims. | PSNet
    psnet.ahrq.gov/issue/understanding-diagnostic-safety-emergency-medicine-case-case-review-closed-ed-malpractice
    May 11, 2019 - Study Understanding diagnostic safety in emergency medicine: a case‐by‐case review … Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice … Understanding diagnostic safety in emergency medicine: A case-by-case review of closed ED malpractice

97. What can safety cases offer for patient safety? A multisite case study. | PSNet
    psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study
    February 07, 2024 - A multisite case study. Citation Text: Liberati EG, Martin GP, Lamé G, et al. … A multisite case study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042. … In this study, researchers use the “safety case” approach to evaluate the safety of the Safer Clinical … A multisite case study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042. … August 20, 2018 Improving employee voice about transgressive or disruptive behavior: a case

98. Making the business case for quality and safety. | PSNet
    psnet.ahrq.gov/issue/making-business-case-quality-and-safety
    January 19, 2022 - Commentary Making the business case for quality and safety. … Making the business case for quality and safety. … case-based vignettes as examples. … Making the business case for quality and safety. … July 23, 2010 The business case for patient safety.

99. Surgical Patient Safety: A Case-Based Approach. | PSNet
    psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach
    February 14, 2018 - Book/Report Surgical Patient Safety: A Case-Based Approach. … Citation Text: Surgical Patient Safety: A Case-Based Approach. Stahel PF, ed. … textbook provides an introduction to nontechnical aspects of safe surgical practice, a collection of case … Cite Citation Citation Text: Surgical Patient Safety: A Case-Based

100. Strengthening the Business Case for Patient Safety | PSNet
     psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
     May 01, 2013 - Strengthening the Business Case for Patient Safety Peter K. … Strengthening the Business Case for Patient Safety. PSNet [internet]. … Strengthening the Business Case for Patient Safety. PSNet [internet]. … How good do you think the state of case-mix adjustment is? … Strengthening the Business Case for Patient Safety. PSNet [internet].