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3241. An Inadvertent Bolus of Norepinephrine. | PSNet
      psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
      December 04, 2016 - a prospective, observational Canadian ICU study pre-dating EHR implementation found that incomplete documentation

3242. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60721/psn-pdf
      July 21, 2020 - Special Edition Perspective: Technology Responses to COVID-19 July 21, 2020 Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19 Editor’s note: This …

3243. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet
      psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
      October 27, 2022 - SPOTLIGHT CASE Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations Citation Text: Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. Rockville (MD): Agency for He…

3244. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33644/psn-pdf
      December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…

3245. Double Dose at Transfer | PSNet
      psnet.ahrq.gov/web-mm/double-dose-transfer
      November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

3246. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49530/psn-pdf
      February 01, 2007 - Rapid Mis-St(r)ep February 1, 2007 Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/rapid-mis-strep The Case A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F, sore throat, and diffuse abdominal pain. There was no history…

3247. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49866/psn-pdf
      June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

3248. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33778/psn-pdf
      March 01, 2015 - Diagnostic Errors January 1, 2014 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/diagnostic-errors Annual Perspective 2014 Until very recently, diagnostic errors received relatively little attention in the field of patient safety, particularly when compared wi…

3249. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33824/psn-pdf
      January 01, 2016 - Patient Safety and Opioid Medications January 1, 2016 Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications Annual Perspective 2016 Opioid medications confer significant risks of harm, including overdose death …

3250. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49862/psn-pdf
      May 01, 2019 - The Magnetic Deflection May 1, 2019 Kanal E. The Magnetic Deflection. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/magnetic-deflection The Case A 68-year-old woman with a prior history of cerebrovascular accident and hypertension presented to the hospital with new left-sided weakness and hypertensive urg…

3251. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49448/psn-pdf
      June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …

3252. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49393/psn-pdf
      April 01, 2003 - Which End Is Which? April 1, 2003 Campbell AR. Which End Is Which? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/which-end-which The Case A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic diverting colostomy to divert her fecal stream and allow the perine…

3253. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49439/psn-pdf
      March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…

3254. Spotlight
      psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
      January 01, 2020 - Spotlight Spotlight Suicidal Ideation in the Family Medicine Clinic 1 Source and Credits This presentation is based on the December 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Christine Moutier, MD, Chief Medical Officer, American …

3255. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…

3256. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33815/psn-pdf
      September 01, 2016 - Telemedicine and Patient Safety September 1, 2016 Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety Perspective A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…

3257. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33812/psn-pdf
      August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…

3258. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49842/psn-pdf
      September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

3259. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49520/psn-pdf
      September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…

3260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49635/psn-pdf
      September 01, 2011 - Central, not Epidural September 1, 2011 Simmons D. Central, not Epidural. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/central-not-epidural The Case A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively, he was awake, alert, and oriented to time, place,…