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5541. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

5542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49406/psn-pdf
      June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…

5543. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49631/psn-pdf
      July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…

5544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850362/psn-pdf
      June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…

5545. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33623/psn-pdf
      December 01, 2005 - The Unintended Consequences of Florida Medical Liability Legislation December 1, 2005 Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation Perspective Quality health …

5546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49791/psn-pdf
      April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…

5547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49650/psn-pdf
      March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…

5548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49463/psn-pdf
      October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

5549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60547/psn-pdf
      May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020 Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety Introduction The Food and Drug Administration (FDA) plays a critical role in ensuring the …

5550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49832/psn-pdf
      June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …

5551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

5552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836942/psn-pdf
      April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m…

5553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49659/psn-pdf
      July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…

5554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…

5555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49700/psn-pdf
      February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients February 1, 2014 Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/nonsustaine…

5556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49821/psn-pdf
      February 01, 2018 - Right Place, Right Drug, Wrong Strength February 1, 2018 Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength The Case A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…

5557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49551/psn-pdf
      December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

5558. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…

5559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49805/psn-pdf
      September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…

5560. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
      August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…