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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49814/psn-pdf
    December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49853/psn-pdf
    February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49680/psn-pdf
    March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49840/psn-pdf
    September 01, 2018 - Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care September 1, 2018 Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49719/psn-pdf
    September 01, 2014 - No BP During NIBP September 1, 2014 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/no-bp-during-nibp The Case An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anes…
  8. 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…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49776/psn-pdf
    November 01, 2016 - Continuity Errors in Resident Clinic November 1, 2016 Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic The Case A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty concentrating. …
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49491/psn-pdf
    September 01, 2005 - Time of Death? September 1, 2005 Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/time-death The Case An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed. A code was ca…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49613/psn-pdf
    November 01, 2010 - Mother's Milk, but Whose Mother? November 1, 2010 Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother The Case A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been exclusively breastfed…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47523/psn-pdf
    December 05, 2018 - Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment. December 5, 2018 Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring Providers and the Emergency Department…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45105/psn-pdf
    May 11, 2016 - Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: a retrospective observational study. May 11, 2016 Elliott RA, Lee CY, Beanland C, et al. Medicines Management, Medication Errors and Adverse Medication Events in Older People Referred to …
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49811/psn-pdf
    November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies November 1, 2017 Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies The Cases Case #1: A 47-year-old man with a history of hyperthyroidism and h…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49825/psn-pdf
    April 01, 2018 - When Patients and Providers Speak Different Languages April 1, 2018 Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages Case Objectives Understand the legal and regulatory obligations to prov…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49439/psn-pdf
    March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49635/psn-pdf
    September 01, 2011 - Central, not Epidural September 1, 2011 Simmons D. Central, not Epidural. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/central-not-epidural The Case A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively, he was awake, alert, and oriented to time, place,…

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