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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50756/psn-pdf
    December 18, 2019 - A Mistaken Dose of Naloxone? December 18, 2019 Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone The Case A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up appointment. He h…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49872/psn-pdf
    August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49403/psn-pdf
    June 01, 2003 - Missed Appendicitis June 1, 2003 Adams JG. Missed Appendicitis. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missed-appendicitis Case Objectives Appreciate the variable presentations of appendicitis List complications of missed appendicitis Understand the advantages and disadvantages of CT in diagnosing…
  4. psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49638/psn-pdf
    January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33711/psn-pdf
    May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions May 1, 2011 Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions Perspective The Instit…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49775/psn-pdf
    November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets November 1, 2016 McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets The Case A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33618/psn-pdf
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety September 1, 2005 Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety Perspective Translation…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846127/psn-pdf
    March 15, 2023 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists March 15, 2023 Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among- spec…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49706/psn-pdf
    January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue April 1, 2014 Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue The Case A 24-year-old wom…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49620/psn-pdf
    February 01, 2011 - Silent Pain in the Neck February 1, 2011 Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/silent-pain-neck The Case A 60-year-old man with no significant past medical history underwent an elective anterior cervical discectomy for persistent right arm weakness due to cervi…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49398/psn-pdf
    May 01, 2003 - Bloody BP Cuff May 1, 2003 Madan AK. Bloody BP Cuff. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bloody-bp-cuff The Case Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleed…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33733/psn-pdf
    July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes July 1, 2012 Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes Perspe…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73998/psn-pdf
    October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters October 27, 2021 Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters The Case A 6-week-old infant underwent a craniotomy and excision of abnormal bra…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33675/psn-pdf
    October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It? October 1, 2008 Naessens JM. Identifying Adverse Events Not Present on Admission: Can We Do It? PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it Perspective Interest is growi…
  19. psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
    September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis Citation Text: Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  20. Psn-Pdf (pdf file)

    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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