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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - alternative feeding methods must be measured with regard to growth, health, development, and all other short
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/ExecSummcaseplancustsvce-RAND7607.pdf
July 01, 2007 - refine the
intervention.
5
Monitor
improvements to
make sure they
hold.
6
2
The Short
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Teamwork_in_QI_2012_02_01_Transcript.pdf
January 01, 2012 - That will start to really bring in regular team meetings and even huddles, like short huddles in the
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - sedating medications at once or when different opioid prescriptions are provided in overlapping or short
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psnet.ahrq.gov/curated-library/diagnostic-error
September 14, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term
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www.ahrq.gov/sites/default/files/2024-04/wolfson-report.pdf
January 01, 2024 - physicians
operate among an opaque set of incentives of which they may be only dimly aware—falls far
short
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www.ahrq.gov/hai/tools/mvp/modules/cusp/forming-cusp-team-fac-guide.html
February 01, 2017 - Slide 15: Engage the Senior Executive
Say:
This short video called "Engaging the Senior Executive
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - Slide 14
Engage the Senior Executive
SAY:
This short video called "Engaging the Senior Executive"
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www.ahrq.gov/hai/cauti-tools/archived-webinars/building-team-process-slides.html
December 01, 2017 - Building a Team and Process to Reduce CAUTI Risk
Slide Presentation
Slide 1
Mohamad Fakih, MD, MPH
Professor of Medicine
Wayne State University School of Medicine
Medical Director, Infection Prevention and Control
St. John Hospital and Medical Center
Barbara Lucas, MD, MHSA
Project Consultant
Mich…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/sustainability/sustaining-guide.pdf
March 01, 2017 - This how-to guide is organized into short sections on critical factors to successfully improve and
sustain
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
August 20, 2015 - This step involves using the knowledge and the momentum from short-term wins to align an organization
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
June 02, 2025 - Walks Occasionally:
Walks occasionally during day, but for very short distances, with or without assistance
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www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
December 01, 2012 - In short, a Just Culture is a system that holds itself accountable, holds staff members accountable,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
June 02, 2025 - SAY:
The “Understand the Science of Safety” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members. By analyzing patient safety as a science, frontline providers will provide a h…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-8-approaches-to-qi.pdf
September 01, 2015 - Think long-term planning, not short-
term reaction.
2. “Adopt the new philosophy.”
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www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - Comprehensive curricula and instructional guides include short case studies and videos illustrating teamwork
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4d_combo_psi07-crbsi-bestpractices.pdf
May 20, 2016 - documents/MSH/volumeii/infectioncontrol/handwashin
g_1.pdf
• JHH Policy for the Care of Patient with Short
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - theory include the systems-theoretic accident model and processes ( 14 ) and AcciMap methods.( 15 ) A short
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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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