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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49505/psn-pdf
    March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49845/psn-pdf
    October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49697/psn-pdf
    December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49647/psn-pdf
    February 01, 2012 - Amended Lab Results: Communication Slip February 1, 2012 Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip The Case A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension an…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49775/psn-pdf
    November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets November 1, 2016 McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets The Case A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49432/psn-pdf
    February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error February 1, 2004 Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error Case Objectives Understand the importance of ongoing patient re-evaluati…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49620/psn-pdf
    February 01, 2011 - Silent Pain in the Neck February 1, 2011 Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/silent-pain-neck The Case A 60-year-old man with no significant past medical history underwent an elective anterior cervical discectomy for persistent right arm weakness due to cervi…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49398/psn-pdf
    May 01, 2003 - Bloody BP Cuff May 1, 2003 Madan AK. Bloody BP Cuff. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bloody-bp-cuff The Case Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleed…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49484/psn-pdf
    June 01, 2005 - Two Pills, Same Drug June 1, 2005 Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/two-pills-same-drug The Case A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past medical history included several AIDS-related complica…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49492/psn-pdf
    November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49607/psn-pdf
    August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49722/psn-pdf
    December 01, 2014 - Medical Devices in the "Wild" December 1, 2014 Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medical-devices-wild The Case A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49784/psn-pdf
    February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49691/psn-pdf
    September 01, 2013 - DRESSed for Failure September 1, 2013 Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dressed-failure The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand cellulitis and an uncomplicated urinary tract infec…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49569/psn-pdf
    September 01, 2008 - Where's the Feeding Tube? September 1, 2008 Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wheres-feeding-tube The Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury. Because of the injuries, he was unabl…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49429/psn-pdf
    January 01, 2004 - Ruptured Heterotopic Pregnancy January 1, 2004 Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy The Case A 43-year-old woman, gravida 3 para 2, presented at 16 weeks' gestational age with abdominal pain. Her current pregnancy was the r…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49751/psn-pdf
    January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49596/psn-pdf
    December 01, 2009 - Round-Trip Service December 1, 2009 McGrath MH. Round-Trip Service. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/round-trip-service The Case A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms in his left knee. He was referred by his primary care provid…

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