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4961. 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…

4962. 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…

4963. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49538/psn-pdf
      June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

4964. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73999/psn-pdf
      October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …

4965. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49718/psn-pdf
      January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…

4966. 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…

4967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49625/psn-pdf
      May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…

4968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49715/psn-pdf
      August 21, 2014 - Liver Biopsy: Proceed With Caution August 21, 2014 Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution The Case A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast cancer, presented t…

4969. Outbreak | PSNet
      psnet.ahrq.gov/web-mm/outbreak
      January 29, 2015 - Outbreak Citation Text: Rothman R, Stapleton S. Outbreak. 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 …

4970. Check the Anesthesia Machine | PSNet
      psnet.ahrq.gov/web-mm/check-anesthesia-machine
      August 01, 2006 - Check the Anesthesia Machine Citation Text: Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

4971. Diagnostic Errors Case Studies | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
      September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case Studies  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Maria Mirica, PRIDE Group …

4972. Collegiality vs. Competence | PSNet
      psnet.ahrq.gov/web-mm/collegiality-vs-competence
      August 28, 2024 - Collegiality vs. Competence Citation Text: Sagin T. Collegiality vs. Competence. 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 tagg…

4973. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49666/psn-pdf
      October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…

4974. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
      January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

4975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837660/psn-pdf
      July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…

4976. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49834/psn-pdf
      July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…

4977. Delayed Sepsis Management Due to Ambiguous Allergy | PSNet
      psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
      January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy Citation Text: Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Schol…

4978. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures Citation Text: Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: …

4979. Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts  Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotl…

4980. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet
      psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
      July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…