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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Transfusion "Slip"
February 1, 2004
Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/transfusion-slip
The Case
A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma
center after a half-ton truck that had skidded out of control struck…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/49694/psn-pdf
October 01, 2013 - Are You Mrs. A? An Issue of Identification Over
Telephone
October 1, 2013
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
The Case
Mr. A was a 78-year-old man admitted with non-ST elevation…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - Over Not So Easy
Citation Text:
Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/node/49526/psn-pdf
December 01, 2006 - Crossing the Borderline
December 1, 2006
Oldham JM. Crossing the Borderline. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/crossing-borderline
The Case
A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit
following a failed suicide attempt with excess doses…
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. 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/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49800/psn-pdf
July 01, 2017 - The Hidden Harms of Hand Sanitizer
July 1, 2017
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
The Case
A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital
for community-acquired pn…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies
Citation Text:
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - SPOTLIGHT CASE
Triple Handoff
Citation Text:
Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/wheres-feeding-tube
September 01, 2003 - Where's the Feeding Tube?
Citation Text:
Metheny NA, Meert KL. Where's the Feeding Tube?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - A Real Heartache
Citation Text:
Polevoi SK. A Real Heartache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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