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81. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
    April 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision … Gone Bad Source and Credits This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case … evidence on the effectiveness of quality improvement efforts to reduce inappropriate antibiotic use Case … Head Neck Surg. 2007;133:260-265. http://www.ncbi.nlm.nih.gov/pubmed/17372083 Issues in Present Case … Case (cont.): Antibiotics for URI The patient’s hospital course was marked by multiorgan failure, septic

82. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
    October 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case October 2004 Thin Air Source and Credits This presentation … is based on the Oct. 2004 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov … in human procedures Review strategies to prevent delivery of wrong gas to hospitalized patients Case … Case (cont.): Thin Air The patient was intubated for hypoxemic respiratory failure. … What Went Wrong in This Case Tubing connected to green Christmas tree adapter which was inadvertently

83. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
    November 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case November 2008 Dangerous Shift Source and Credits … This presentation is based on the November 2008 AHRQ WebM&M Spotlight Case See the full article at … expertise and error Learn three heuristics for effective coordination: Reduce, Reveal, Focus Case … Case: Dangerous Shift (2) The off-going nurse assumed the transfer would take place immediately and … Case: Dangerous Shift (3) The evening physician was also contacted, and was equally surprised by the

84. Spotlight Case September 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
    September 01, 2003 - Spotlight Case September 2003 Spotlight Case September 2003 Infant Paralyzed for Intubation Before … Materials Ready Source and Credits This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case … activity, participants should be able to: Understand and apply a structured method of human factors case … Case (cont.): Infant Paralyzed Upon review of the event, the team discovered that the nurse was new to … for CFA of this case Contributory Factor Analysis (cont.)

85. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
    December 01, 2012 - Spotlight Case July 2008 Spotlight Case The Lung Nodule That Refused To Grow * * Source and Credits … This presentation is based on the December 2012 AHRQ WebM&M Spotlight Case See the full article at … benign disease Understand when patients no longer need surveillance for benign disease * * Case … * Case: Lung Nodule (2) Upon further history, the patient stated that while undergoing a hernia … * Case: Lung Nodule (3) The patient had a 6-month follow-up CT scan in 2004 confirming the nodule

86. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - AHRQ Impact Case Studies Criteria AHRQ Impact Case Studies provide evidence of how AHRQ-funded … Each Impact Case Study demonstrates how AHRQ-funded resources are actually being used to improve the … Impact Case Studies are developed by AHRQ's Office of Communications (OC) based on leads that are provided … Each Impact Case Study must meet basic criteria to move beyond the lead stage. … Criteria Development of an Impact Case Study starts by collecting leads.

87. 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

88. 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

89. 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

90. 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

91. 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

92. 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

93. 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

94. Case Study | Digital Healthcare Research
    digital.ahrq.gov/research-method/case-study
    January 01, 2024 - Case Study A case study on language barriers, health literacy, and family … A case study on language barriers, health literacy, and family interpretation: What is ethical communication … Role network measures to assess healthcare team adaptation to complex situations: the case … Role network measures to assess healthcare team adaptation to complex situations: the case of venous … A multi-level usability evaluation of mobile health applications: a case study.

95. Impact Case Studies on the SOPS Surveys | Agency for Healthcare Research and Quality
    www.ahrq.gov/sops/resources/case-studies.html
    March 01, 2025 - Impact Case Studies on the SOPS Surveys AHRQ’s collection of Impact Case Studies highlights … Below are success stories from organizations that used the SOPS Surveys grouped by year the case study … Case Studies Published Between 2021 – Present University of Georgia Health Center Relies on AHRQ Survey … to Assess Culture of Safety and Quality   Case Studies Published Between 2016–2020 ChristianaCare Used … Promote Patient Safety Sudan Teaching Hospitals Use AHRQ’s Patient Safety Culture Survey and TeamSTEPPS Case

96. Case Studies | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwp2.html
    August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions Case Studies Previous … Page Table of Contents High-Performance Work Practices in CLABSI Prevention Interventions Case … Case Study Sites Table 2. Summary of Key Informants, All Sites Table 3. … Final Report: Executive Summary (continued) For this task order we conducted indepth case … Case Study Process The case studies included site visits between June 2011 and October 2012 to nine

97. 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

98. 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

99. Clinical Case Scenarios | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/clinical-case-scenarios.html
    July 01, 2023 - Clinical Case Scenarios AHRQ Safety Program for Perinatal Care, Phase 2 The two clinical case … Obstetric Hemorrhage Clinical Case Scenarios (PowerPoint, 5.5 MB) Severe Hypertension Clinical Case … to the 10 teamwork tools and strategies and showcase their use during a hemorrhage or hypertension case … Conceptual explanation of the tools is followed with a segment from the clinical case scenario that demonstrates

100. 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)