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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/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - One Dose, Two Errors
December 1, 2016
Filice GA. One Dose, Two Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/one-dose-two-errors
The Case
A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory
failure secondary to community-acquired pneumonia. The pati…
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psnet.ahrq.gov/node/49481/psn-pdf
May 01, 2005 - Discharge Against Medical Advice
May 1, 2005
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice
The Case
A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the
medical service with mild alco…
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Double Trouble
September 1, 2005
Gurwitz JH. Double Trouble. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/double-trouble
Case Objectives
Appreciate the incidence of adverse drug events in older persons
List preventative measures that can be used to minimize medication errors in this population
Encourage…
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psnet.ahrq.gov/node/49668/psn-pdf
October 01, 2012 - Buprenorphine and the Medically Ill Patient
October 1, 2012
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
The Case
A 60-year-old man with a 15-year history of oxycodone dependence presented to a substance …
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
In Conversation with… Edward Tenner, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and
culture. He received his PhD fro…
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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Don't Use That Port: Insert a PICC
Citation Text:
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The Forgotten Med
Citation Text:
Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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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/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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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…
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…