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3921. 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…

3922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49703/psn-pdf
      March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …

3923. Psn-Pdf (pdf file)
      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 …

3924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49492/psn-pdf
      November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…

3925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49688/psn-pdf
      August 21, 2013 - Discharge Instructions in the PACU: Who Remembers? August 21, 2013 Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Case A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …

3926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49523/psn-pdf
      November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…

3927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49576/psn-pdf
      January 01, 2009 - To Transfer or Not to Transfer January 1, 2009 Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer Case Objectives Explore the benefits of the continuity of hospital care. Understand the rules and regulations behind triage and hospital choice de…

3928. Psn-Pdf (pdf file)
      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…

3929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33673/psn-pdf
      September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety in hospitals depends on the successful execu…

3930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860049/psn-pdf
      January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. January 4, 2024 Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient The Case A 9…

3931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33775/psn-pdf
      December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned December 1, 2014 Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned Perspective In the last 6 years I have had the privilege of sha…

3932. Psn-Pdf (pdf file)
      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…

3933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

3934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49472/psn-pdf
      March 01, 2005 - Preventable Rash March 1, 2005 McLean C. Preventable Rash. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit, screening laboratories were checked. The clinic never contacted th…

3935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72587/psn-pdf
      December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…

3936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851158/psn-pdf
      June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization June 28, 2023 Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case A patient was …

3937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33772/psn-pdf
      September 01, 2014 - In Conversation With… Rosemary Gibson, MSc September 1, 2014 In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA Internal Medicin…

3938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49637/psn-pdf
      October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…

3939. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls | PSNet
      psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
      February 17, 2021 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls Citation Text: Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…

3940. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. 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 En…