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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Are We Pushing Graduate Nurses Too Fast?
Citation Text:
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
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psnet.ahrq.gov/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error
Citation Text:
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.
Citation Text:
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. 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/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital
Citation Text:
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - A Potent Medication Administered in a Not So Viable Route
Citation Text:
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati…
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and
Impending Perforation
July 31, 2023
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
The Case
A 56-year-…
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…