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41. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
    January 01, 2021 - multiple preventable errors over several clinical visits culminated in a devastating outcome 4 Case Details … • He was sent home from clinic with advice to take over-the-counter analgesics. 5 Case Details … worsening headache, nausea, vomiting and photophobia – He was given oxycodone for pain 6 Case Details … the hospital and was admitted with a presumptive diagnosis of Staphylococcal meningitis. 7 Case Details … (1) Case Details (2) Case Details (3) Case Details (4) Dangers of missing an epidural abscess: multiple

42. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
    January 01, 2021 - error” in care – and the importance of early palliative care referral and intervention 4 Case Details … radiotherapy (to relieve pain and obstructive symptoms) and then was lost to follow up. 5 Case Details … • He was discharged to an inpatient hospice for comfort care. 6 Case Details (3) • After thoroughly … of this patient’s life, these details are vital to an understanding of why he stopped going to his … (1) Case Details (2) Case Details (3) Culture Clash No More: �Integration and Coordination of Disease

43. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
    January 01, 2022 - patient checklist, latex product buying practices, and medical safety committee oversight. 5 Case Details … antibiotics were administered during the procedure and repair of the diverticulum was uneventful. 6 Case Details … device insertion was rapidly recognized, and the drain was replaced with a silicone drain. 7 Case Details … Perioperative Anaphylaxis after insertion of a latex drain in a patient with known latex allergy Case Details … (1) Case Details (2) Case Details (3) Perioperative anaphylaxis after insertion of a latex drain

44. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - high-risk scenarios contributed to the missed diagnosis of fatal intracranial hemorrhage 4 Case Details … and performed but it is unclear whether the ordering physician ever reviewed the images 5 Case Details … recommended therapeutic low molecular weight heparin and next-day cardiology follow up 6 Case Details … hemorrhage and ultimately brainstem herniation • Patient was placed on comfort care and later died Case Details

45. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - documentation and communication, and the impact of limited resources during the night shift 4 Case Details … transferred to the inpatient floor – The medication list was not updated during the transition 5 Case Details … anxiety, resulting in a total of 4 doses (16 mg) of IV lorazepam over the course of 12-hours 6 Case Details … morning nurse unsure as to the cause of the decrease in mental status and low blood oxygen 7 Case Details

46. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. | PSNet
    psnet.ahrq.gov/issue/unintended-discontinuation-medication-following-hospitalisation-retrospective-cohort-study
    September 05, 2018 - March 1, 2023 Medication details documented on hospital discharge: cross-sectional observational … March 28, 2011 Medication details documented on hospital discharge: cross-sectional observational

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837330/psn-pdf
    June 08, 2022 - This article details next steps for incorporating competencies into interprofessional health education

48. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837666/psn-pdf
    July 13, 2022 - equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41998/psn-pdf
    January 30, 2013 - involving-patients-improving-safety This review analyzes research on engaging patients in safety improvement and details

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866640/psn-pdf
    September 04, 2024 - This article details a quality and patient safety improvement project aimed at increasing reporting

51. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38006/psn-pdf
    August 20, 2008 - cardiac-arrest-during-anesthesia This article reviews factors contributing to anesthesia-related cardiac arrests and details

52. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854833/psn-pdf
    October 25, 2023 - This report details five wrong-site surgeries and three instances of retained surgical items at one

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39507/psn-pdf
    April 28, 2010 - April 28, 2010 https://psnet.ahrq.gov/issue/hospital-infections-hard-gauge This news piece details

54. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42181/psn-pdf
    April 10, 2013 - think-you-cant-make-medication-errors This article describes examples of medication safety failures and details

55. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39593/psn-pdf
    June 09, 2010 - https://psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-trigger-dangers This news piece details errors

56. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39524/psn-pdf
    January 17, 2012 - https://psnet.ahrq.gov/issue/computerized-medication-order-errors-studied This news article details

57. Scathing report on Kaiser kidney program. Transplant delays assailed -- Medicare threatens to end coverage. | PSNet
    psnet.ahrq.gov/issue/scathing-report-kaiser-kidney-program-transplant-delays-assailed-medicare-threatens-end
    March 29, 2023 - This article reports on a Centers for Medicare & Medicaid Services report that details deficiencies in

58. Think you can't make medication errors? | PSNet
    psnet.ahrq.gov/issue/think-you-cant-make-medication-errors
    March 01, 2023 - This article describes examples of medication safety failures and details methods to help prevent them

59. Spotlight
    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - managing complex trauma cases and the vital role of clear communication among care teams 4 4 Case Details … remained mechanically ventilated for altered mentation and presumed aspiration pneumonitis. 5 5 Case Details … not documented in progress notes by either the trauma team or the spine surgery team. 6 6 Case Details … described the neurological exam as “moves all extremities” during hospital days 5-10. 7 7 Case Details … real time to the full complement of dynamic clinical information about a patient, including historical details

60. Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report. | PSNet
    psnet.ahrq.gov/issue/review-quality-care-and-treatment-provided-14-hospital-trusts-england-overview-report
    August 02, 2023 - investigation into care delivered at National Health Service trusts with high mortality rates, this report details