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41. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
    March 01, 2009 - Spotlight Case July 2008 Spotlight Case All in the History Source and Credits This presentation … is based on the February/March 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … emergency physicians and inpatient physicians differ in their approach to patient diagnoses Case … Case: All in the History (2) In the code room, the physician found an elderly man with no pulse, no … Emergency Medical Services (EMS) Handoff This case highlights potential for lost information at the

42. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits … This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http:/ … for handoff evaluation, including the application of a framework for clinical supervision * * Case … * * Case: Perils of Cross Coverage (2) Her WBC started to trend down, and she was afebrile for … * * Case: Perils of Cross Coverage (4) Subsequent root cause analysis determined that earlier

43. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
    November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation … is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … threshold that should be used in hospitalized patients with and without coronary artery disease 3 Case … was given diuretics and discharged to a skilled nursing facility (SNF) for rehabilitation. 4 4   Case … patient to be transferred to the emergency department (ED) for evaluation and transfusion. 5 5 Case

44. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
    March 01, 2012 - Spotlight Case July 2008 Spotlight Case Postdischarge Follow-Up Phone Call * * Source and Credits … This presentation is based on the March 2012 AHRQ WebM&M Spotlight Case See the full article at http … call program List common pitfalls when establishing a postdischarge phone call program * * Case … * * Case: Postdischarge Phone Call (3) That afternoon she received a call from the hospital. … * * Case: Postdischarge Phone Call (4) The nurse who had called previously called again 2 days

45. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
    December 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case December 2004 Discharge Fumbles Source and Credits This … presentation is based on the Dec. 2004 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full … Case #1 (cont.): Discharge Fumbles He presented to the emergency department (ED) and was found to be … Case #2: Discharge Fumbles A patient was admitted for atypical chest pain. … Case #2 (cont.): Discharge Fumbles The patient presented to the ED the following day with mental status

46. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
    May 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case May 2008 Diagnosing HIV: It Doesn’t Take a Brain Surgeon … Source and Credits This presentation is based on the May 2008 AHRQ WebM&M Spotlight Case See … challenges associated with HIV screening practices Review current guidelines for HIV screening Case … Case: Diagnosing HIV (2) The radiologist reported the findings to be concerning for a malignant rather … Case: Diagnosing HIV (3) Upon arrival to the referral facility, the patient remained neurologically

47. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits … This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full … Discuss how medication reconciliation decreases the opportunity for medication errors and harm Case … Case (cont.): Reconciling Doses After 2 days, the patient was transitioned to Augmentin. … Case (cont.): Reconciling Doses At the time of discharge, the patient’s INR was noted to be 4.

48. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
    September 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case September 2004 Poor Prognosis? … Source and Credits This presentation is based on the September 2004 AHRQ WebM&M Spotlight Case in Surgery … in elderly patients Appreciate the cognitive steps to determine prognosis in elderly patients Case … Case (cont.): Poor Prognosis Otorhinolaryngology (ENT) evaluation revealed no evidence of laryngeal … Case (cont.): Poor Prognosis After further discussion, the family decided to withdraw care, because

49. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
    June 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case June 2007 Beeline to Spine Source and Credits This … presentation is based on June 2007 AHRQ WebM&M Spotlight Case See full article at http://webmm.ahrq.gov … The case against routine preoperative laboratory testing. … The case against routine preoperative laboratory testing. … The case against routine preoperative laboratory testing.

50. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
    February 01, 2010 - Spotlight Case July 2008 Spotlight Case Adolescent Diabetes: A Routine Visit? … Source and Credits This presentation is based on the February 2010 AHRQ WebM&M Spotlight Case See … Review some common errors in the care of adolescent patients and strategies to prevent them Case … Case: Adolescent Diabetes (2) She had presented to the clinic 18 months earlier with fatigue and polyuria … Case: Adolescent Diabetes (4) On physical examination, she was a quiet, depressed morbidly obese girl

51. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
    September 01, 2012 - Spotlight Case July 2008 Spotlight Case Peripheral IV in Too Long 1 2 Source and Credits This presentation … is based on the September 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … IVs in the hospital State how frequently peripheral IVs should be changed in adult patients 3 4 Case … that called for all peripheral IV catheters to be replaced after 4 days to prevent infection. 4 5 Case … Arch Intern Med. 1998;158:473-477. http://www.ncbi.nlm.nih.gov/pubmed/9508225 10 Case: In Too Long

52. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
    February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits … This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at … * * Case: One Toxic Drug A 50-year-old man was diagnosed with chronic hepatitis C (viral load of … * This Case: Set-up for Error Experienced physician in a different discipline Familiar and … company denied the hospital bill, and the medical director for case management was asked to prepare

53. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.92_slideshow.ppt
    April 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case April 2005 Compare and Contrast Source and Credits This … presentation is based on the April 2005 Spotlight Case in Emergency Medicine See the full article … pharmacologic strategies for CN prophylaxis Follow algorithm for CN risk reduction and prevention Case … factors, but increased to 11.2% with one risk factor and more than 20% with two risk factors.5 Case … Case (cont.): Compare and Contrast Due to continued oliguria and persistent uremia hemodialysis was

54. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
    May 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case May 2007 Antiseizure Medication Disorder Source and … Credits This presentation is based on the May 2007 AHRQ WebM&M Spotlight Case See the full article … pharmacokinetics of phenytoin List clinical scenarios when phenytoin levels may be unreliable Case … Case: Antiseizure Medication Disorder On physical exam, his vital signs were unremarkable and he had … Case: Antiseizure Medication Disorder The rest of his electrolytes, renal function, and liver function

55. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? … Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full … Case: Delirium or Dementia? (2) At admission, the patient appeared mildly dehydrated. … Case: Delirium or Dementia? (3) Overnight, nursing staff noted the patient to be disoriented. … Case: Delirium or Dementia?

56. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
    December 01, 2009 - Spotlight Case [MONTH] 2003 Spotlight Case Standard Deviations Source and Credits This presentation … is based on the December 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … psychiatric consultations in patients whose refusal to cooperate with treatment is perplexing Case … Understanding service disengagement from the perspective of case managers. … Understanding service disengagement from the perspective of case managers.

57. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
    September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and … Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article … in nursing homes Describe what is being done or can be done to make nursing homes safer * * Case … * * Case: Safety of Long Term Care (2) During an unassisted transfer from her wheelchair to her … * * Case: Safety of Long Term Care (3) A few weeks later, she continued to remain bedbound with

58. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
    July 01, 2012 - Spotlight Case July 2008 Spotlight Case Not-So-Therapeutic Tap * * Source and Credits This presentation … is based on the July 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … * * Case: Not-So-Therapeutic Tap (2) The second-year resident had performed 6 paracenteses as … * * Case: Not-So-Therapeutic Tap (4) About 20 minutes later, the intern was called due to the … * * Case: Not-So-Therapeutic Tap (5) A stat angiogram revealed a bleeding omental vessel that

59. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? … Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the … including error disclosure Review potential support structures for providers involved in errors Case … Case: How Do Providers Recover from Errors? … Case: How Do Providers Recover from Errors? Consent was obtained from the patient and his wife.

60. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
    April 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Bad Writing, Wrong Medication * * Source and Credits … This presentation is based on the April 2010 AHRQ WebM&M Spotlight Case See the full article at http … Case: Bad Writing, Wrong Medication (1) * * Case: Bad Writing, Wrong Medication (2) Shortly after … Med Care. 2005;43:1171-1176. http://www.ncbi.nlm.nih.gov/pubmed/16299427 * Case: Bad Writing, Wrong … In This Case This medication error was a preventable ADE and caused patient harm System improvements