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4021. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet
      psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
      July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room Citation Text: Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

4022. The Dropped "No" | PSNet
      psnet.ahrq.gov/web-mm/dropped-no
      October 30, 2019 - The Dropped "No" Citation Text: Johnson AJ. The Dropped "No". 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 …

4023. Preventable Rash | PSNet
      psnet.ahrq.gov/web-mm/preventable-rash
      October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. 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 RIS …

4024. The Fluidity of Diagnostic "Wet Reads" | PSNet
      psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
      April 24, 2018 - The Fluidity of Diagnostic "Wet Reads" Citation Text: Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

4025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49871/psn-pdf
      August 10, 2019 - Renal Failure Due to Benign Prostatic Hyperplasia August 10, 2019 Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia The Case A 65-year-old man was referred to urology for a 5-year history of …

4026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73650/psn-pdf
      August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…

4027. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
      psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
      September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

4028. Patient Identification Errors: A Systems Challenge | PSNet
      psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
      February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

4029. Liposuction Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/liposuction-gone-awry
      July 01, 2003 - Liposuction Gone Awry Citation Text: Yates JA. Liposuction Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

4030. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet
      psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
      February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …

4031. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72834/psn-pdf
      March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…

4032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49419/psn-pdf
      October 01, 2003 - The Other Side October 1, 2003 Vincent CA. The Other Side. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/other-side Case Objectives List the factors contributing to wrong site surgery. Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surger…

4033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49630/psn-pdf
      July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…

4034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857260/psn-pdf
      November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! November 30, 2023 Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/when…

4035. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
      May 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case May 2008 Diagnosing HIV: It Doesn’t Take a Brain Surgeon Source and Credits This presentation is based on the May 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Roger Chou, MD, Oregon Health &…

4036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49545/psn-pdf
      September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent coronary angiography because of atypical exertional chest…

4037. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49440/psn-pdf
      March 01, 2004 - Autopsy Revelation March 1, 2004 Shojania KG. Autopsy Revelation. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/autopsy-revelation The Case A 45-year-old male with development delay presented to the emergency department with acute abdominal pain. His mother, who was his main caregiver, accompanied him. Th…

4038. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865984/psn-pdf
      May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…

4039. Diffusion of Responsibility Leads to Danger | PSNet
      psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
      November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…

4040. Urinary Retention Dilemma | PSNet
      psnet.ahrq.gov/web-mm/urinary-retention-dilemma
      March 01, 2013 - Urinary Retention Dilemma Citation Text: Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…