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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…
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - One Toxic Drug Is Not Like Another
February 1, 2011
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
Case Objectives
Distinguish between the three distinct regulatory processes of board certification, medical licensure,
and credential…
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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…
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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…
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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…
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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…
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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. …
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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…
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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…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - dedicated nurses and pharmacists available to manage inpatients receiving chemotherapy
See Notes for reference … and pharmacists to ensure proper dosing and administration
Structured documentation
See Notes for reference
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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…
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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…
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psnet.ahrq.gov/issue/improving-medication-management-through-redesign-hospital-code-cart-medication-drawer
October 31, 2018 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/do-professional-interpreters-improve-clinical-care-patients-limited-english-proficiency
November 30, 2016 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/report-6-managing-risk-and-minimising-mistakes-services-children-and-families
June 13, 2012 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
-
psnet.ahrq.gov/issue/culture-safety-ems-systems-0
February 18, 2011 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
-
psnet.ahrq.gov/issue/medication-prescribing-errors-prehospital-setting-and-ed
September 13, 2017 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
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psnet.ahrq.gov/issue/preventing-mistransfusions-evaluation-institutional-knowledge-and-response
June 06, 2018 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
-
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…
-
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,…