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9341. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49785/psn-pdf
      February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…

9342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49680/psn-pdf
      March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …

9343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33705/psn-pdf
      January 01, 2011 - Risk Management and Patient Safety December 1, 2010 Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety Perspective In 1990, a Harvard-based research team reported the incidence of medical errors …

9344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49704/psn-pdf
      March 01, 2014 - Late Anemia Following Rh Disease in a Newborn March 1, 2014 Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn The Case A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…

9345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49494/psn-pdf
      January 01, 2006 - One Dose, Fifty Pills November 1, 2005 Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills The Case A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis. When the initial diagnostic studies failed to provide …

9346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49521/psn-pdf
      September 12, 2006 - A Troubling Amine September 1, 2006 Flynn EA. A Troubling Amine. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/troubling-amine The Case A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure. She was found to have severe mitral and tricuspid valve regurgi…

9347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49533/psn-pdf
      March 01, 2007 - Staggered Sensitivity Results March 1, 2007 Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results The Case A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck dissection, and pectoralis fla…

9348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49724/psn-pdf
      January 01, 2015 - Bowel Injury After Laparoscopic Surgery January 1, 2015 Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery The Case A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…

9349. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
      psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
      September 28, 2022 - attributed to access barriers to primary care, and to the fact that many of the patients seen in emergency departments

9350. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865884/psn-pdf
      May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…

9351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60610/psn-pdf
      June 24, 2020 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis June 24, 2020 Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis   The Case A 15-year-old g…

9352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49553/psn-pdf
      January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…

9353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33708/psn-pdf
      March 01, 2011 - In Conversation with…Vineet Arora, MD, MA March 1, 2011 In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma Editor's note: Vineet Arora, MD, MA, is Associate Program Director for the Internal Medicine Residency and Assistant Dea…

9354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60329/psn-pdf
      May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD May 14, 2020 In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md Editor’s note: Joel Willis, DO, PA, M…

9355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60856/psn-pdf
      August 26, 2020 - Too Many Cooks in the Kitchen August 26, 2020 Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/too-many-cooks-kitchen Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Un…

9356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861760/psn-pdf
      January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

9357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846169/psn-pdf
      March 15, 2023 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. March 15, 2023 Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/…

9358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…

9359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49525/psn-pdf
      December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…

9360. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
      psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
      July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 29, 2024 View more articles from the same authors. Inno…