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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure
Citation Text:
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/42917/psn-pdf
February 05, 2014 - The PROMISES Project.
February 5, 2014
Brigham and Women's Hospital; Institute for Healthcare Improvement; Massachusetts Coalition for the
Prevention of Medical Errors; Coverys; CRICO; Harvard School of Public Health; Harvard Medical School;
Health Care for All; Massachusetts Medical Society; Massachusetts Departme…
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - SPOTLIGHT CASE
Monitoring Fetal Health
Citation Text:
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
January 01, 2016 - Charcoal Lavage of the Lungs
Citation Text:
Wigton RS. Charcoal Lavage of the Lungs. 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/49634/psn-pdf
September 01, 2011 - Situational (Un)Awareness
September 1, 2011
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/situational-unawareness
The Case
A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver
function tests, including a bi…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - The Wrongful Resuscitation
April 1, 2008
Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrongful-resuscitation
The Case
An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and
poor quality of life had previously been r…
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psnet.ahrq.gov/node/49847/psn-pdf
November 01, 2018 - Written Signout: It Only Works If You Use The Right One
November 1, 2018
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
The Case
A 75-year-old man was hospitalized due to a stro…
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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - Defensive Medicine: "Glowing" with Pain
February 1, 2010
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
The Case
A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and
vomiting. The…
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psnet.ahrq.gov/web-mm/crossing-borderline
June 01, 2022 - Crossing the Borderline
Citation Text:
Oldham JM. Crossing the Borderline. 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/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/web-mm/one-dose-fifty-pills
January 13, 2021 - One Dose, Fifty Pills
Citation Text:
Smith L. One Dose, Fifty Pills
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Double Trouble
September 1, 2005
Gurwitz JH. Double Trouble. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/double-trouble
Case Objectives
Appreciate the incidence of adverse drug events in older persons
List preventative measures that can be used to minimize medication errors in this population
Encourage…
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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