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psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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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…
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psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - A Little Shuteye
Citation Text:
Farion KJ. A Little Shuteye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/check-bags
January 03, 2017 - Check the Bags
Citation Text:
Caldwell M, Dracup KA. Check the Bags. 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/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downloa…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. 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/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - The Forgotten Turn
December 1, 2010
Barbour S. The Forgotten Turn. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/forgotten-turn
Case Objectives
Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel.
List risk factors for the development of pressure ulcers in hospita…
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. 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/weighing-surgical-safety
August 04, 2021 - SPOTLIGHT CASE
Weighing In on Surgical Safety
Citation Text:
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. 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/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. 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/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Duplicate Insulin Order
Citation Text:
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarette Explosion in a Patient Room
Citation Text:
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors
April 1, 2013
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
Case Objectives
Define parenteral nutrition (PN).
Describe the PN-use process.
Identify …