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4701. 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…

4702. 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…

4703. Point-of-care Mixup: 1 Shot Turns Into 3 | PSNet
      psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
      February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…

4704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

4705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49713/psn-pdf
      June 01, 2014 - CVC Removal: A Procedure Like Any Other June 1, 2014 Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other The Case A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the hospital for a p…

4706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

4707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49397/psn-pdf
      May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…

4708. 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…

4709. 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…

4710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33881/psn-pdf
      August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…

4711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49837/psn-pdf
      August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…

4712. 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…

4713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49736/psn-pdf
      June 01, 2015 - Inflicting Confusion June 1, 2015 Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/inflicting-confusion The Case A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with acute-onset abdominal pain, nausea, vomiting, an…

4714. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49459/psn-pdf
      September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …

4715. 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…

4716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33699/psn-pdf
      August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…

4717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

4718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49674/psn-pdf
      December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…

4719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73515/psn-pdf
      August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents July 28, 2021 https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing- home-residents Summary The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…

4720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33685/psn-pdf
      May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA May 1, 2009 In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and Family M…