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21. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
    May 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case May 2005 Diagnosing Diagnostic Mistakes Source and … Credits This presentation is based on the May 2005 AHRQ WebM&M Spotlight Case See the full article … WebM&M Case Analysis The case is considered to “dramatically and tragically” illustrate a diagnostic … She later dies of an aortic dissection and the case is presented as a diagnostic error. … WebM&M Case Analysis Initial diagnosis of acute coronary syndrome reasonable due to lower base rates

22. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
    May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error … * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case … * * Case: Right Regimen, Wrong Cancer (2) In the morning his bedside nurse for the day came in … * * Case: Right Regimen, Wrong Cancer (3) Rather than the 3-day regimen for metastatic penile … Informed patients can catch some errors, as in this case. *

23. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
    February 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case February 2006 Lost in Transition Source and Credits … This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case See the full article at … of transitions in emergency care Provide suggestions to decrease risk at shift transitions Case … Case (cont.): Lost in Transition Sixty minutes after arrival, the patient was admitted to the internal … Case (cont.): Lost in Transition The outgoing ED physician had just completed the shift, and signed

24. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
    April 01, 2009 - Spotlight Case July 2008 Spotlight Case Breakage of a PICC Line * * Source and Credits This … presentation is based on the April 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … breakage Understand the risk factors for PICC line breakage Understand the treatment options in case … Appreciate the guidelines to reduce risk of complications from central venous catheters * * Case … * * Case: PICC Line Breakage (3) After several attempts to retrieve the remainder of the line

25. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
    September 01, 2008 - Spotlight Case July 2008 Spotlight Case Empiric Steroids: the Good, the Bad, and the Ugly Source … and Credits This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case See the full … Understand which chronic illnesses and systemic diseases can benefit from glucocorticoid use Case … Case B: Part 1 (cont.) … Case C: Part 1 (cont.) On examination he appeared ill and was mildly tachypneic.

26. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
    October 01, 2012 - Spotlight Case July 2008 Spotlight Case CA-MRSA Skin Infections: An Ounce of Prevention is Worth a … * * Source and Credits This presentation is based on the October 2012 AHRQ WebM&M Spotlight Case … * Case: CA-MRSA Skin Infection (2) As the week progressed, he noticed the bump was increasingly … She immediately took her son to the emergency department (ED). * Case: CA-MRSA Skin Infection (5) … A radiograph showed extensive erosion at the femur head secondary to osteomyelitis. * Case: CA-MRSA

27. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
    June 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation … is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … At the time of induction, she was given fentanyl, etomidate, and rocuronium. 4 5 Case: Emergency … The hospital's case review committee felt the patient likely had severe acute pancreatitis and not a … How long will the case take? What is the anticipated blood loss?

28. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
    October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits … This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at … units List the regulatory agencies with a role in dialysis unit patient safety oversight * * Case … * * Case: Dangerous Dialysis (2) The dialysis center was actually not sure which dialysis membrane … * * Case: Dangerous Dialysis (3) The patient was tested for HIV and hepatitis viruses and was

29. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
    November 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Treatment Challenges After Discharge * * Source and … Credits This presentation is based on the November 2010 AHRQ WebM&M Spotlight Case See the full article … Case: Treatment after Discharge (1) * * After a urine culture was obtained in the ED, the patient … Case: Treatment after Discharge (2) * * Transitions in Care 2.3 million ED visits each year by … With the correct antibiotic, the patient made a full recovery. * Case: Treatment after Discharge (5)

30. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
    October 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case October 2003 Hemivulvectomy: Wrong Side Removed Source … and Credits This presentation is based on the Oct. 2003 AHRQ WebM&M Spotlight Case in OB/GYN See … an authority gradient Understand the challenges and consequences of disclosing medical errors Case … Case (cont.): Wrong Side Surgery The next day, the Chief of Pathology called the trainee to inquire … about the case.

31. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - Spotlight Case July 2008 Spotlight Case Watch the Warfarin! … 1 2 Source and Credits This presentation is based on the July 2011 AHRQ WebM&M Spotlight Case See the … in the safe management of warfarin Recognize the risks and benefits of newer anticoagulants 3 4 Case … for his atrial fibrillation, and this medication was continued while he was in the hospital. 4 5 Case … to any of the medications he was taking before the hospitalization, including the warfarin. 5 6 Case

32. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
    March 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case March 2007 Failure to Report Source and Credits This … presentation is based on the March 2007 AHRQ WebM&M Spotlight Case See the full article at http:// … and near misses Discuss steps individuals and institutions can take to increase reporting Case … Case: Failure to Report (cont.) … Committed to Safety: Ten Case Studies on Reducing Harm to Patients.

33. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
    November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences … Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case … Describe unintended consequence of public reporting and interventions to prevent these The Case … The Case The work-up revealed that the patient’s anticoagulation with warfarin was subtherapeutic, and … The Case (cont.) Later that day, the patient complained of pain over her right upper arm.

34. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source … Case: cont. The patient became hypotensive with a systolic blood pressure (BP) of 65 mm Hg. … Case: cont. … Case: cont. Norepinephrine was weaned rapidly. The patient remained on vasopressin. … Case: cont. Within the next few hours, the patient’s condition improved.

35. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
    October 01, 2008 - Spotlight Case July 2008 Spotlight Case Recurrent Hypoglycemia: A Care Transition Failure? … * * Source and Credits This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case … access across population groups, and new entrants into the personal health record space * * Case … * * Case: Recurrent Hypoglycemia (2) The patient did not speak English. … * * Issues in Present Case Case report does not mention whether patient’s primary physician received

36. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
    December 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case December 2005 Low on the Totem Pole Source and Credits … This presentation is based on the Dec. 2005 Spotlight Case in Surgery/Anesthesia See the full article … across an authority gradient Consider the current culture of safety in your own institution Case … Case: Low on the Totem Pole The student observed one of the team members insert a Foley catheter into … Case (cont.): Low on the Totem Pole After rounds, two attendings approached the student, separately.

37. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
    October 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case October 2007 Do Not Disturb! … Source and Credits This presentation is based on the October 2007 AHRQ WebM&M Spotlight Case See the … Case: Do Not Disturb! (cont.) … Physician Competencies This case identifies intertwined failures in four physician competencies that … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9032162 Case: Do Not Disturb! (cont.)

38. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research … Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case … plans Appreciate system capacities for covering sudden changes and overload situations * * Case … Case: Nurse Staffing Ratios (2) The nurse implemented the initial orders as the patient was stabilized … He began to transition to intermittent, rather than continuous, nebulizer treatments. * * Case:

39. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case July 2007 Resuscitation Errors: A Shocking Problem … Source and Credits This presentation is based on the July 2007 AHRQ WebM&M Spotlight Case See the … rescuers at their institution to assess the readiness of the defibrillator and its components Case … Case: Resuscitation Errors The cardiology resident arrived and confirmed torsades on the monitor. … db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=2485837 Case: Resuscitation Errors (cont

40. Spotlight Case September 2006 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
    September 01, 2006 - Spotlight Case September 2006 Spotlight Case September 2006 Triple Handoff Source and Credits … This presentation is based on the September 2006 AHRQ WebM&M Spotlight Case See the full article … of a safe and effective written and verbal signout List Kotter’s 8 steps to leading change Case … Case: Triple Handoff The patient was sent to the recovery unit for overnight monitoring. … Case: Triple Handoff At 10:00 p.m. the nurse asked the night float resident about the x-ray.