-
psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…
-
psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
-
psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
-
psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
February 26, 2025 - RW : You mentioned earlier that the organization is moving a bit from just the measurement part of the
-
psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
-
psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - RW: You mentioned that a large part of the motivation at UCSF Health was the finding on physician
satisfaction
-
psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - In addition, as mentioned earlier, nocturnal headaches that keep patients awake at night should prompt
-
psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - For example, the physician-patient mentioned above tried to engage senior leadership in focusing the
-
psnet.ahrq.gov/node/33714/psn-pdf
July 01, 2011 - RW: You mentioned that what appears to be the greatest motivation so far is the legal protections offered
-
psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - Although postdischarge phone calls were not specifically
mentioned in the Transitions of Care Consensus
-
psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - Of the possible causes mentioned above, the only other causes that might lead to a mistaken call of PE
-
psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - RW: You mentioned government regulations and meaningful use were well meaning.
-
psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
RW: You mentioned the complexity
-
psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - RW: It struck me as you were describing the challenges, you mentioned Atul Gawande for the surgical one
-
psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - Though not specifically mentioned in this case, an additional red flag to inquire about is bowel/bladder
-
psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - The obstetric team had not mentioned this
information during the previous huddle.
5
Case Details
-
psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - course, system-level issues that limit in-person bedside evaluations by cross-covering providers (as mentioned
-
psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - Finally, it must be mentioned that this error occurred in the context of two high-risk clinical domains
-
psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - He then called the medicine team and mentioned that he found a very small effusion on the right side,
-
psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - Allergy to Holter
July 1, 2004
Williams M. Allergy to Holter. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/allergy-holter
The Case
A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4
the patient was sent to the cardiac clinic to start a continuous …