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61. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
    April 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case April 2006 Is the “Surgical Personality” a Threat to Patient … Source and Credits This presentation is based on the April 2006 AHRQ WebM&M Spotlight Case See the … Case: Wire we here? … Case (cont.): Wire we here? … Case (cont.): Wire we here?

62. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
    December 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case December 2007 Elopement Source and Credits This presentation … is based on the December 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … Case: Elopement On the morning of anticipated discharge, the patient was not in his room at the time … Case (cont.): Elopement Ultimately, the patient was found outside the emergency department, with ED … Case (cont.): Elopement Even though the ED staff had noted the patient to be mildly confused, in the

63. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
    January 01, 2015 - Spotlight Case [MONTH] 2003 Spotlight Case February 2007 The ‘Customer’ Is Always Right Source … and Credits This presentation is based on the February 2007 AHRQ WebM&M Spotlight Case See the full … the relationship between patient-centered care and safety, quality, and patient satisfaction Case … Case: The ‘Customer’ Is Always Right Physical exam revealed a fussy child with normal vital signs and … Case: The ‘Customer’ Is Always Right The resident advised the mom that a fracture was unlikely based

64. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
    July 01, 2008 - Spotlight Case July 2008 Spotlight Case July 2008 Dependence vs. … Case: Dependence vs. … Available at: http://www.ncbi.nlm.nih.gov/pubmed/15204675 Issues in Present Case In this case, … Case (cont.): Dependence vs. … Case (cont.): Dependence vs.

65. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
    May 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case May 2004 Too Tight Control: The Risks of Intensive Insulin … Therapy Source and Credits This presentation is based on the May 2004 AHRQ WebM&M Spotlight Case … Understand the difference between efficacy and effectiveness with regards to results of clinical trials Case … Infection and diabetes: the case for glucose control. … cmd=Retrieve&db=PubMed&list_uids=11242719&dopt=Abstract   Case (cont.): Too Much of a Good Thing

66. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
    February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? … 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See … errors occur with e-prescribing Describe steps to limit errors associated with e-prescribing 3 4 Case—Part … complaints, the primary care doctor elected to prescribe an antianxiety agent, alprazolam. 4 5 Case—Part … “3 times a day,” instead of pharmacist having to change instructions manually 16 17 Notes about Case

67. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
    October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This … presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http:/ … for patients in the ICU Describe potential exercises and activities for patients in the ICU * Case … * * Case: Mobility Lost in ICU (2) Shortly after admission, the patient developed altered mental … ICU) stay for respiratory failure from an ischemic cardiac event and aspiration pneumonia. * * Case

68. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and … Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME … specific steps that institutions can take to enhance the disclosure of harmful errors to patients Case … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14724310 Case (cont.): The Wrong Shot After the … incident, the physician in this case felt responsible for the loss of trust and the missed opportunity

69. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation … is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … of guidelines and standardization, which can make patient transfers between hospitals safer 3 4 Case … 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.

70. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
    December 01, 2011 - Spotlight Case July 2008 Spotlight Case Order Interrupted by Text: Multitasking Mishap * * Source … and Credits This presentation is based on the December 2011 AHRQ WebM&M Spotlight Case See the full … care setting List best practices and policies for using mobile devices in health care * * Case … * * Case: Multitasking Mishap (5) The resident never completed the order to discontinue warfarin … * * Case: Multitasking Mishap (7) The patient’s INR was 8.5 at the time, indicating his blood

71. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
    September 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case September 2007 Medication Reconciliation: Whose Job Is It … Source and Credits This presentation is based on the September 2007 AHRQ WebM&M Spotlight Case See … Case: Medication Reconciliation (cont.) … Case: Medication Reconciliation (cont.) … Case: Medication Reconciliation (cont.)

72. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
    April 01, 2013 - Spotlight Case July 2008 Spotlight Case Total Parenteral Nutrition, Multifarious Errors * * Source … and Credits This presentation is based on the April 2013 AHRQ WebM&M Spotlight Case See the full article … Identify potential PN-related medication errors Describe methods to reduce PN-related errors * * Case … * * Case: Errors with PN (3) In the morning, labs were notable for serum sodium of 158 mEq/L, … * * Case: Errors with PN (4) On formal case review, multiple errors led to the excess sodium

73. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
    September 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case September 2005 Double Trouble Source and Credits … This presentation is based on the Sept. 2005 AHRQ WebM&M Spotlight Case See the full article at http … errors in this population Encourage patients to take an active role in their pharmaceutical care Case … Case (cont.) … members Impact of adherence on ADEs has not been documented but is likely an important factor Case

74. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
    July 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case July 2006 Moving Pains Source and Credits This presentation … is based on the June/July 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … Case: Moving Pains This change in respiratory status occurred while the primary nurse was occupied by … Case: Moving Pains Since the nurse was unaware of the change in the patient’s respiratory status, she … Case (cont.): Moving Pains Over the next hour, the patient’s condition continued to worsen.

75. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
    July 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Weighing in on Surgical Safety * * Source and Credits … This presentation is based on the July 2010 AHRQ WebM&M Spotlight Case See the full article at http … Case: Surgical Safety * * Although the patient tried to lose weight many times, his body mass index … Case: Surgical Safety (2) * * Background Obesity is an increasing problem Overweight is BMI > … Anesth Analg. 2009;109:1182-1186. http://www.ncbi.nlm.nih.gov/pubmed/19762747 * * Case: Surgical

76. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
    March 01, 2011 - Spotlight Case July 2008 Spotlight Case March 2011 Volume Too Low: In and Out Pediatric Patient Safety … * * Source and Credits This presentation is based on the March 2011 AHRQ WebM&M Spotlight Case … * * Case: Pediatric Patient Safety (1) A 22-month-old infant was admitted to the hospital in … * * Case: Pediatric Patient Safety (2) Later in the evening, the infant drank 2 ounces (60 mL … * * Case: Pediatric Patient Safety (3) His total urine output overnight as documented by the

77. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
    December 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case December 2006 Hidden Heparins: HIT Happens Source … and Credits This presentation is based on the December 2006 AHRQ WebM&M Spotlight Case See the full … management of HIT Identify safeguards to avoid future exposure to heparin in individuals with HIT Case … Case (cont.): Hidden Heparins She appeared to be improving with a decrease in WBC to 10 x 109/L. … Case (cont.): Hidden Heparins Autopsy revealed thrombi in the vessels of skin of breast and abdomen.

78. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
    November 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case November 2003 The Missing Suction Tip Source and Credits … This presentation is based on the Nov. 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article … The patient’s surgery, scheduled as the second case of the day, began in mid-afternoon. … cmd=Retrieve&db=PubMed&list_uids=10635432&dopt=Abstract Case (cont.): Missing Suction Tip While … Missing Tip: Contributing Factors Obesity Patient weighed 124 kg Fatigue Afternoon case lasting 7

79. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
    March 01, 2013 - Spotlight Case July 2008 Spotlight Case A Weighty Mistake * * Source and Credits This presentation … is based on the March 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … automation complacency Identify strategies for reducing weight-based dosing medication errors * * Case … * * Case: A Weighty Mistake (2) The following evening, the patient's mother called the ED to report … information can propagate seemingly obvious medication dosing errors That is what occurred in this case

80. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
    December 01, 2010 - Spotlight Case July 2008 Spotlight Case The Forgotten Turn * * Source and Credits This presentation … is based on the December 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov … * * Case: Forgotten Turn (2) Because of a bed shortage, the patient remained in the ED for 8 … * * Case: Forgotten Turn (3) The day nurse found the patient to be confused but oriented, pleasant … * * Case: Forgotten Turn (4) In mid-afternoon, the nurse and patient care assistant came to turn