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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…
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psnet.ahrq.gov/node/49504/psn-pdf
March 01, 2006 - Liposuction Gone Awry
March 1, 2006
Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/liposuction-gone-awry
The Case
A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s
office, he underwent neck and facial liposuction wit…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
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…
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psnet.ahrq.gov/node/49458/psn-pdf
September 01, 2004 - Poor Prognosis
September 1, 2004
Lamont EB. Poor Prognosis. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/poor-prognosis
Case Objectives
Understand the current limitations of physicians' ability to provide prognoses.
List the variables that can be used to guide treatment decisions and prognostication in e…
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psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - Who Nose Where the Airway Is?
October 1, 2009
Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/who-nose-where-airway
The Case
A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular
bypass surgery on his right upper extrem…
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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…
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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/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 …
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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/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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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…
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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/node/49856/psn-pdf
March 01, 2019 - Premature Extubation
March 1, 2019
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/premature-extubation
The Case
A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid
endarterectomy. The procedure was initially thought to …
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - Vial Mistakes Involving Heparin
Citation Text:
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. 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 tagged PubMe…
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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.
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Format:
Google Scholar…
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital
Citation Text:
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with
Thromboembolism.
November 16, 2022
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
The Case
A 61-year-old woman presented to …
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement
Citation Text:
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy…
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Preventing Falls Through Patient and Family Engagement
to Create Customized Prevention Plans
May 31, 2023
https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-
customized-prevention
Summary
Patient falls in hospitals are common and debilitating adverse events that persis…