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psnet.ahrq.gov/web-mm/wrong-channel
February 01, 2003 - October 28, 2020
WebM&M Cases
Preventing Complications
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - significant patient morbidity and even mortality.(
3,9,10) Patients can experience immediate postoperative complications
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - While the
complications and ultimate outcome of this case are exceedingly rare, unfortunately, the problem
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - the inpatient psychiatric unit used the case as an opportunity to broadly consider not only medical complications
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psnet.ahrq.gov/node/49498/psn-pdf
January 01, 2006 - IVC filters may be useful for
patients with transiently increased risk of both clotting and bleeding complications
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - associated with multiple adverse events including
progressive loss of kidney function, major cardiac complications
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - October 28, 2020
WebM&M Cases
Preventing Complications
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
October 01, 2012 - infection with incision and drainage
Unfortunately, this patient represents the very rare case where complications
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - this
patient that will not only reduce their fall risk and harm injury, but also may prevent other complications
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psnet.ahrq.gov/node/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
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psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
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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
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
…
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - PowerPoint Presentation
Spotlight
A ʺReflexiveʺ Diagnosis in Primary Care
1
This presentation is based on the April 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - October 16, 2019
View More
See More About The Topic
Dentistry
Medical Complications … Nonsurgical Procedural Complications
Quality Improvement Strategies
Education and Training
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - overtesting, which can lead to excessive
healthcare costs and potential harm from procedure-related complications … Postoperative
Complications Following Repair of Acute Achilles Tendon Rupture.