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1341. Double Dose at Transfer | PSNet
      psnet.ahrq.gov/web-mm/double-dose-transfer
      November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

1342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49674/psn-pdf
      December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…

1343. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49734/psn-pdf
      May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…

1344. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

1345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49476/psn-pdf
      March 02, 2005 - Around the Block March 1, 2005 Minichiello T. Around the Block. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/around-block The Case A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee replacement. The orthopedic surgeon, recognizing the risk of deep vein th…

1346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

1347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33739/psn-pdf
      October 01, 2012 - The Physical Environment: An Often Unconsidered Patient Safety Tool October 1, 2012 Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool Perspective Now that…

1348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49718/psn-pdf
      January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…

1349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49444/psn-pdf
      May 01, 2004 - Do Me a Favor May 1, 2004 Williamson A. Do Me a Favor. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/do-me-favor The Case A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she had a positive home pregnancy test. With a history of one ectopic pregnancy, one…

1350. Paradoxical Pulse | PSNet
      psnet.ahrq.gov/web-mm/paradoxical-pulse
      May 01, 2013 - Paradoxical Pulse Citation Text: Roy CL. Paradoxical Pulse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1351. Walking Patient, Missing Drain | PSNet
      psnet.ahrq.gov/web-mm/walking-patient-missing-drain
      April 01, 2006 - Walking Patient, Missing Drain Citation Text: Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …

1352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49717/psn-pdf
      September 01, 2014 - A Lot of Pain (Medications) September 1, 2014 Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/lot-pain-medications Case Objectives Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids. Describe the importance of understanding th…

1353. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet
      psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
      March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

1354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49491/psn-pdf
      September 01, 2005 - Time of Death? September 1, 2005 Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/time-death The Case An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed. A code was ca…

1355. Time of Death? | PSNet
      psnet.ahrq.gov/web-mm/time-death
      January 03, 2017 - Time of Death? Citation Text: Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

1356. The Perils of Cross Coverage | PSNet
      psnet.ahrq.gov/web-mm/perils-cross-coverage
      September 22, 2010 - SPOTLIGHT CASE The Perils of Cross Coverage Citation Text: Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX En…

1357. Another Fall | PSNet
      psnet.ahrq.gov/web-mm/another-fall
      June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

1358. The Pains of Chronic Opioid Usage | PSNet
      psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
      April 04, 2018 - SPOTLIGHT CASE The Pains of Chronic Opioid Usage Citation Text: Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google S…

1359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49392/psn-pdf
      April 01, 2003 - Another Fall April 1, 2003 Bogardus SG. Another Fall. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized patients Understand appropriate use of restraints Identify system issues contributing to falls in hospitalized patients Case & Comm…

1360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49528/psn-pdf
      January 01, 2015 - The "Customer" Is Always Right February 1, 2007 Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/customer-always-right Case Objectives Understand the importance of identifying a patient's agenda. Appreciate the factors that contribute to unmet patient expectations. …