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7421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

7422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49577/psn-pdf
      January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…

7423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49590/psn-pdf
      January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…

7424. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

7425. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60169/psn-pdf
      March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…

7426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49701/psn-pdf
      February 01, 2014 - An Easily Forgotten Tube February 1, 2014 Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/easily-forgotten-tube The Case A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol abuse. His illness was complicated by acute…

7427. 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…

7428. Lap Burn | PSNet
      psnet.ahrq.gov/web-mm/lap-burn
      March 01, 2018 - Lap Burn Citation Text: Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…

7429. The Challenges of Aggregating Patient Data from Multiple Sites (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006King_051611comp.pdf
      June 16, 2021 - The Challenges of Aggregating Patient Data from Multiple Sites Volunteer eHealth Initiative The Challenges of Aggregating Patient Data from Multiple Sites Janet King Technical Project Manager Regional Health Initiatives Vanderbilt Center for Better Health Funding: AHRQ Contract 290-04-0006; State of Tennessee;…

7430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49435/psn-pdf
      February 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…

7431. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
      February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…

7432. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49514/psn-pdf
      July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…

7433. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866621/psn-pdf
      August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

7434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33681/psn-pdf
      March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …

7435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49428/psn-pdf
      January 01, 2004 - To Resuscitate or Not? January 1, 2004 Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/resuscitate-or-not The Case A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease, his code status was Do Not Resuscitate/…

7436. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
      February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

7437. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49477/psn-pdf
      April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…

7438. 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…

7439. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49841/psn-pdf
      September 01, 2018 - Chemotherapy Administration Safety Standards September 1, 2018 Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…

7440. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60790/psn-pdf
      February 23, 2022 - pandemic may require dentists to change their workflows62,63 or re-configure their clinic layouts besides ensuring