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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49547/psn-pdf
    October 01, 2007 - Code Blue—Where To? October 1, 2007 Adams BD. Code Blue—Where To? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/code-blue-where The Case An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxi…
  3. 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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49475/psn-pdf
    March 01, 2005 - Techno Trip March 1, 2005 Cook RI. Techno Trip. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/techno-trip The Case A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49664/psn-pdf
    January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49833/psn-pdf
    June 01, 2018 - Perils in Diagnosing a Stroke June 1, 2018 Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke The Case A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was brought to the emergency depart…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49426/psn-pdf
    November 01, 2003 - Don't Push November 1, 2003 Meltzer HY. Don't Push. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dont-push The Case A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
    April 01, 2013 - Spotlight Case July 2008 Spotlight Case Total Parenteral Nutrition, Multifarious Errors * * Source and Credits This presentation is based on the April 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49593/psn-pdf
    October 01, 2009 - Who Nose Where the Airway Is? October 1, 2009 Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/who-nose-where-airway The Case A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular bypass surgery on his right upper extrem…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49562/psn-pdf
    May 01, 2008 - The Inside of a Time Out May 1, 2008 Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/inside-time-out The Case A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm. The patient had an allergy to "IV contrast dye" that was no…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49749/psn-pdf
    December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin December 1, 2015 Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin The Case A 47-year-old man with type 2 diabetes was admitted to the hospita…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49818/psn-pdf
    January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis January 1, 2018 Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis The Case A 50-year-old man presented to a primary care clinic to establish care, as he ha…
  14. 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 …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49694/psn-pdf
    October 01, 2013 - Are You Mrs. A? An Issue of Identification Over Telephone October 1, 2013 Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone The Case Mr. A was a 78-year-old man admitted with non-ST elevation…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49823/psn-pdf
    March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure March 1, 2018 Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure The Case An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
  17. 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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49739/psn-pdf
    August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…

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