222 lines
20 KiB
HTML
222 lines
20 KiB
HTML
<!doctype html>
|
|
<!--[if lt IE 7]> <html class="no-js lt-ie9 lt-ie8 lt-ie7" lang="en"> <![endif]-->
|
|
<!--[if IE 7]> <html class="no-js lt-ie9 lt-ie8" lang="en"> <![endif]-->
|
|
<!--[if IE 8]> <html class="no-js lt-ie9" lang="en"> <![endif]-->
|
|
<!-- Consider adding a manifest.appcache: h5bp.com/d/Offline -->
|
|
<!--[if gt IE 8]><!--> <html class="no-js" lang="en"> <!--<![endif]-->
|
|
<head>
|
|
<meta charset="utf-8" />
|
|
|
|
<meta name="perc_linkback" id="perc_linkback" content="FmZjYGdheAdgeAFjZ2x4BmZnYHgTY2xibGM="/> <!-- Use the .htaccess and remove these lines to avoid edge case issues. More info: h5bp.com/i/378 -->
|
|
<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1" />
|
|
<title>AHRQ Web M&M | AHRQ Archive</title>
|
|
<meta name="title" content="AHRQ Web M&M | AHRQ Archive" />
|
|
<meta name="description" content="Fact sheet describes Web M&M, a peer-reviewed online journal that uses a case-based approach to educate providers and trainees about patient safety." />
|
|
|
|
<!-- Mobile viewport optimized: h5bp.com/viewport -->
|
|
<meta name="viewport" content="width=device-width" />
|
|
<!-- link rel="stylesheet" href="/css/style.css" -->
|
|
|
|
<!-- More ideas for your <head> here: h5bp.com/d/head-Tips -->
|
|
<!-- All JavaScript at the bottom, except this Modernizr build.
|
|
Modernizr enables HTML5 elements & feature detects for optimal performance.
|
|
Create your own custom Modernizr build: www.modernizr.com/ -->
|
|
<script src="/js/libs/modernizr-2.5.3.min.js"></script>
|
|
|
|
<!-- "metadata" -->
|
|
<meta name="keywords" content="Agency for Health Care Policy and Research, Agency for Healthcare Research and Quality, AHRQ, AHCPR, access, adverse outcomes, ambulatory care, benchmark, best practices, blood clots, CAHPS, case studies, chronic care, complication, conditions, Consumer Assessment of Health Plans, disparities, error, HAI, health cost, hepatitis, hospital procedure, health care-associated infections, indicators, infection, insurance, measures, medical errors, methodology, nursing, patient care, patient safety, performance measure, quality, study, survey, thrombosis, treatment, urgent care" />
|
|
<meta name="creator" content="Agency for Healthcare Research and Quality (AHRQ)" />
|
|
<meta name="datecreated" content="September 2012" />
|
|
<meta name="datereviewed" content="October 2014" />
|
|
<meta name="language" content="en-us" />
|
|
<!-- end="metadata" -->
|
|
<link rel="stylesheet" href="/css/archive.css" />
|
|
<link rel="stylesheet" href="/css/ahrqstyleprint_arch.css" media="print" />
|
|
<script>
|
|
(function(i,s,o,g,r,a,m){i['GoogleAnalyticsObject']=r;i[r]=i[r]||function(){
|
|
(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),
|
|
m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)
|
|
})(window,document,'script','//www.google-analytics.com/analytics.js','ga');
|
|
|
|
ga('create', 'UA-75759936-1', 'auto');
|
|
ga(' set', 'anonymizeIp', true);
|
|
|
|
ga('send', 'pageview');
|
|
|
|
</script></head>
|
|
<body><!-- Google Tag Manager -->
|
|
<noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-W4DST4"
|
|
height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>
|
|
<script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':
|
|
new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],
|
|
j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src=
|
|
'//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);
|
|
})(window,document,'script','dataLayer','GTM-W4DST4');</script>
|
|
<!-- End Google Tag Manager -->
|
|
<!-- Prompt IE 6 users to install Chrome Frame. Remove this if you support IE 6.
|
|
chromium.org/developers/how-tos/chrome-frame-getting-started -->
|
|
<!--[if lt IE 7]><p class=chromeframe>Your browser is <em>ancient!</em> <a href="http://browsehappy.com/">Upgrade to a different browser</a> or <a href="http://www.google.com/chromeframe/?redirect=true">install Google Chrome Frame</a> to experience this site.</p><![endif]-->
|
|
|
|
<!-- Add your site or application content here -->
|
|
<noscript>Your browser doesn't support JavaScript. Please upgrade to a modern browser or enable JavaScript in your existing browser.</noscript>
|
|
<!-- Page Header v2.0 --><!--Begin Banner CodeS-->
|
|
<div id="ahrqbanner">
|
|
<div class="hhsportion" id="top" name="top">
|
|
<a class="skipnav" href="#h1">Skip Navigation</a>
|
|
<a title="Archive: U.S. Department of Health and Human Services" href="http://archive.hhs.gov/"><img border="0" alt="Archive: U.S. Department of Health and Human Services" src="/images/hhs_banner_arch.gif" width="376" height="49" /></a>
|
|
<a class="hhsright" title="U.S. Department of Health and Human Services" href="http://www.hhs.gov/"><img alt="U.S. Department of Health and Human Services" src="/images/hhs_link_arch.gif" width="127" height="41" /></a>
|
|
</div>
|
|
<div class="ahrqportion">
|
|
<a title="Archive: Agency for Healthcare Research Quality" href="/"><img border="0" alt="Archive: Agency for Healthcare Research Quality" src="/images/ahrq_banner_arch.jpg" width="566" height="69" /></a>
|
|
<form id="banner_searchform" method="get" name="searchForm" action="https://search.ahrq.gov/search">
|
|
<label style="Z-INDEX: -1; POSITION: relative; FONT-SIZE: 0px; MARGIN-RIGHT: -65px" for="search">Search</label>
|
|
<input id="search" class="gotext" onFocus="this.value='';" value=" Search Archive" size="11" type="text" name="q" label="Search archive"/>
|
|
<input type="hidden" name="siteDomain" value="archive.ahrq.gov">
|
|
<input class="gobtn" onClick="javascript:document.searchForm.submit();" alt="Search" src="/images/topbn_GoButton.gif" type="image" name="Submit"/>
|
|
</form><a class="ahrqright" title="AHRQ Home—Live Site" href="http://www.ahrq.gov">www.ahrq.gov</a>
|
|
</div>
|
|
<div class="ahrqlinks">
|
|
<a href="https://www.ahrq.gov/">AHRQ Home—Live Site</a> | <a href="/">Archive Home</a> | <a href="/sitemap.htm">Site Map</a>
|
|
</div>
|
|
</div>
|
|
<div id="PrintBanner"><img alt="Archival print banner" src="/images/printbanner_arch.jpg"/></div><a id="h1" name="h1"></a><!-- End of Page header -->
|
|
<!-- Content Body -->
|
|
<div id="mainContent">
|
|
<!-- Main Content -->
|
|
<!-- Center Content section -->
|
|
<table border="0" cellpadding="0" cellspacing="0" width="100%">
|
|
<tbody><tr valign="top">
|
|
<td width="70%">
|
|
<!-- Center Content section -->
|
|
<table style="margin-left: 10px; margin-right: 10px; margin-top: 5px;" summary="This table gives the layout format of the bread crumb area and the center content area." border="0" cellpadding="0" cellspacing="0" width="100%">
|
|
<!--DWLayoutTable-->
|
|
<tbody><tr>
|
|
<td class="crumb_link"><div id="crumbContent">
|
|
<p></p>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<div id="centerContent">
|
|
<div class="headnote">
|
|
<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information.</p>
|
|
<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p>
|
|
</div>
|
|
<!-- T:ahrqPgPublication -->
|
|
<div role="main" id="page-container">
|
|
<div id="breadcrumb-container">
|
|
<div id="breadcrumbs" class="container_12">
|
|
<!-- T:SnBreadcrumbs -->
|
|
|
|
|
|
|
|
</div>
|
|
</div>
|
|
<div id="toolbar-container">
|
|
<div id="pub-toolbar" class="container_12">
|
|
|
|
<div id="pub-utility-buttons">
|
|
<ul id="utility-groups">
|
|
<li class="utility download-button"><a href="#"><span>Download</span></a><div class="dl-dropdown"><div class="arrow-up"></div><div class="dl-content"><ul><li>
|
|
<span> <img src="/resources/file_logos/pdf.gif" alt="PDF file" title="PDF file" class="icon" /> <a href="/research/findings/factsheets/errors-safety/webmandm/webmandm.pdf">PDF version</a> - 406.93 KB</span>
|
|
</li></ul></div></div></li> </ul>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div id="page-backdrop" class="container_12">
|
|
<div class="page">
|
|
<div id="left-col" class="alpha grid_3">
|
|
<nav id="left"><!-- T:SnleftNav -->
|
|
</nav> </div>
|
|
<!--<div id="content-col" class="grid_9">-->
|
|
<article class="grid_9">
|
|
<!-- Right Rail -->
|
|
<aside class="three-col">
|
|
<div id="pub-nums">
|
|
<ul>
|
|
<li>Publication # 03-0014 </li></ul>
|
|
</div>
|
|
</aside>
|
|
<!-- Center Rail -->
|
|
<h1>AHRQ Web M&M</h1>
|
|
<h2>Online Journal and Forum on Patient Safety and Health Care Quality</h2> <div id="basic-modal"><!-- start: Basic Modal -->
|
|
<p>This peer-reviewed online journal uses a case-based approach to educate providers and trainees about patient safety. Funded by the Agency for Health Care Research and Quality (AHRQ), the site is a collaborative effort with the University of California, San Francisco School of Medicine.</p><h2>Morbidity and Mortality Rounds on the Web</h2><p><a href="http://webmm.ahrq.gov">AHRQ WebM&M</a> is the new peer-reviewed, Web-based journal on patient safety. Funded by the Agency for Healthcare Research and Quality (AHRQ), the site is edited by Drs. Robert Wachter and Kaveh Shojania, along with a team at the University of California, San Francisco (UCSF), with technical support from DoctorQuality. The site is free and has no advertisements.</p><p>AHRQ WebM&M is designed to educate providers and trainees about patient safety and medical errors by using a case-based approach in an engaging, blame-free environment. This site features:</p><ul><li>Cases of medical errors and patient safety issues, with expert commentaries.</li><li>A users' forum.</li><li>Links to patient safety resources.</li></ul><p>The 1999 report by the Institute of Medicine (IOM) <a href="http://books.nap.edu/books/0309068371/html/index.html"><em>To Err is Human: Building a Safer Health System</em></a> concluded that 44,000 to 98,000 Americans die annually from medical errors and created tremendous interest in improving patient safety. Most of the errors cited in the IOM report were due to problems in the health care system rather than individual failures.</p><p>Every month in hospitals across the country, morbidity and mortality (M&M) conferences convene for discussion of specific cases that raise issues regarding medical errors and quality improvement. Although M&M conferences have been a staple at most American hospitals for decades, until now there has been no comparable national forum to discuss and learn from medical errors. AHRQ and the University of California, San Francisco saw the opportunity to use the Web to host a national Morbidity and Mortality conference aimed at improving patient safety through analysis of anonymous cases. This concept evolved into the AHRQ WebM&M site.</p><h2>Case Reports</h2><p>Every month, the site presents five interesting cases of medical errors and patient safety issues—one each in medicine, surgery/anesthesiology, obstetrics-gynecology, pediatrics, and other fields such as psychiatry, emergency medicine, family practice, nursing, etc.</p><p>These cases are submitted anonymously through the Web site. Writers of cases selected for posting will receive an honorarium. Cases will be compelling and provocative, while raising key issues about patient safety and systems improvement.</p><p>Examples of cases include:</p><ul><li><strong>Patient mix-up.</strong> A man almost received medication intended for another patient with the same last name in the same room.</li><li><strong>Unexplained apnea under anesthesia.</strong> A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.</li><li><strong>Flying object hits MRI.</strong> An infusion pump being used for routine sedation in a child undergoing an magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.</li><li><strong>Procedural complications: Learning curve?</strong> A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.</li><li><strong>When "psychiatric" symptoms are medical.</strong> An elderly man with delusions and progressive neurological symptoms, initially attributed to psychosis, was found to have metastatic cancer.</li></ul><h2>Spotlight Case</h2><p>One case each month is developed into a Spotlight Case—an interactive learning module that features an expanded commentary, readers' polls, quizzes, and other multimedia elements. For completion of this educational module, physicians can earn CME credit and trainees can receive certification in patient safety. An electronic slide presentation is also available to download for educational use.</p><h2>Commentaries, Forum, and Resources</h2><p>Each case is followed by a commentary, written by an expert in the field. Discussants in the first few months include:</p><ul><li>Paul Barach, M.D., M.P.H., Jackson Memorial Hospital, and Director Miami Center for Patient Safety, University of Miami.</li><li>Michael Cohen, Pharm.D., Institute for Safe Medication Practices.</li><li>John Gosbee, M.D., M.S., VA National Center for Patient Safety.</li><li>Mary Hannah, M.D., University of Toronto.</li><li>Lucian Leape, M.D., Harvard School of Public Health.</li></ul><p>The commentaries marry an evidence-based approach with observations and analyses, in a lively style that takes advantage of the graphical capabilities of the Internet.</p><p>AHRQ WebM&M includes a users' forum, on which readers can post and react to comments about the cases. The site also provides links to other resources and interesting facts about patient safety, medical errors, and health care quality.</p><h2>Editorial Board and Advisory Panel</h2><p>The editorial team is guided by an Editorial Board and Advisory Panel, comprised of experts in the relevant patient safety and clinical disciplines. In addition to Drs. Cohen, Gosbee, and Leape, its members include David Bates, M.D., of Harvard Medical School; Marilyn Sue Bogner, Ph.D., of the Institute for the Study of Medical Error; Troyen Brennan, M.D., J.D., of Harvard Medical School; Mark Ebell, M.D., M.S., of Michigan State University; Peter Pronovost, M.D., Ph.D., of Johns Hopkins University; Eric Thomas, M.D., of the University of Texas at Houston; and Albert Wu, M.D., of Johns Hopkins University.</p><h2>Getting Involved</h2><p>We encourage you to submit cases and to invite your colleagues to do so as well. To submit a case, or for further information about AHRQ WebM&M, including how to register and obtain CME credit, visit the site or contact us at <a href="mailto:webmm@medicine.ucsf.edu">webmm@medicine.ucsf.edu</a>.</p><ul><li>Robert M. Wachter, M.D., Editor.</li><li>Kaveh G. Shojania, M.D., Deputy Editor.</li><li>Erin E. Hartman, M.S., Managing Editor.</li></ul><h2>CME Credit</h2><p>This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the UCSF School of Medicine and the U.S. Department of Health and Human Services, AHRQ. UCSF is accredited by the ACCME to provide continuing medical education for physicians.</p><p>UCSF designates this educational activity for a maximum of 12 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.</p> </div><!-- end: Basic Modal -->
|
|
<div class="current-as-of">Page last reviewed March 2003</div>
|
|
<div class="citation">
|
|
<span>Internet Citation: AHRQ Web M&M: Online Journal and Forum on Patient Safety and Health Care Quality.
|
|
March 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/factsheets/errors-safety/webmandm/webmandm.html</span>
|
|
<div class="citation-flag"></div>
|
|
</div>
|
|
</article>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<p> </p>
|
|
<div class="footnote">
|
|
<p> The information on this page is archived and provided for reference purposes only.</p>
|
|
</div>
|
|
<p> </p>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</div><!-- End of Content Body -->
|
|
<!-- Footer graphic 1.2-->
|
|
<table border="0" cellSpacing="0" cellPadding="0" width="100%">
|
|
<tbody>
|
|
<tr>
|
|
<td background="/images/bottom_ahrq_bkg.jpg" width="125">
|
|
<img alt="AHRQ" src="/images/bottom_ahrq_1.jpg" width="125" />
|
|
</td>
|
|
<td background="/images/bottom_ahrq_bkg.jpg" width="100%">
|
|
<img alt="" src="/images/bottom_ahrq_bkg.jpg" width="10" height="34" />
|
|
</td>
|
|
<td background="/images/bottom_ahrq_bkg.jpg" width="310">
|
|
<img alt="Advancing Excellence in Health Care" src="/images/bottom_ahrq_2.gif" width="310" height="34" />
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
<!-- Footer links section -->
|
|
<div id="banner_Footer2">
|
|
<p>
|
|
<a href="https://www.ahrq.gov/">AHRQ Home</a> |
|
|
<a class="footer_navlink" href="https://info.ahrq.gov/cgi-bin/ahrq.cfg/php/enduser/std_alp.php">Questions?</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/contact/index.html">Contact AHRQ</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/policy/electronic/accessibility/index.html">Accessibility</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/policy/electronic/privacy/index.html">Privacy Policy</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/news/foia.htm">Freedom of Information Act</a> |
|
|
<a class="footer_navlink" href="https://www.ahrq.gov/policy/electronic/disclaimers/index.html">Disclaimers</a> |
|
|
<a class="footer_navlink" href="http://www.hhs.gov/open/recordsandreports/plainwritingact/index.html">Plain Writing Act</a>
|
|
<br/>
|
|
<a class="footer_navlink" href="http://www.hhs.gov">U.S. Department of Health & Human Services</a> |
|
|
<a class="footer_navlink" href="http://www.whitehouse.gov">The White House</a> |
|
|
<a class="footer_navlink" href="http://www.usa.gov">USA.gov: The U.S. Government's Official Web Portal</a>
|
|
</p>
|
|
</div>
|
|
<div id="banner_Footeraddress">
|
|
<p>
|
|
Agency for Healthcare Research and Quality <img alt="" src="/images/bottom_dot.gif" /> 5600 Fishers Lane Rockville, MD 20857 <img alt="" src="/images/bottom_dot.gif" />
|
|
Telephone: (301) 427-1364
|
|
</p>
|
|
</div>
|
|
<!-- End of Footer links section -->
|
|
|
|
<!-- JavaScript at the bottom for fast page loading: http://developer.yahoo.com/performance/rules.html#js_bottom -->
|
|
<!-- Grab Google CDN's jQuery, with a protocol relative URL; fall back to local if offline -->
|
|
<script src="//ajax.googleapis.com/ajax/libs/jquery/1.7.2/jquery.min.js"></script>
|
|
<script>window.jQuery || document.write('<script src="js/libs/jquery-1.7.2.min.js"><\/script>')</script>
|
|
|
|
<!-- scripts concatenated and minified via build script -->
|
|
<script src="/js/plugins.js"></script>
|
|
<script src="/js/script.js"></script>
|
|
<script src="/scripts/javascript.js"></script>
|
|
<!-- end scripts -->
|
|
</body>
|
|
</html>
|