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psnet.ahrq.gov/node/49649/psn-pdf
March 01, 2012 - Cultural Dimensions of Depression
March 1, 2012
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression
The Case
A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability
to breathe and swallow…
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psnet.ahrq.gov/node/49542/psn-pdf
August 21, 2007 - Copy and Paste
August 21, 2007
Hersh WR. Copy and Paste. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/copy-and-paste
The Case
A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing
her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/49740/psn-pdf
August 21, 2015 - Baffled by Botulinum Toxin
August 21, 2015
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
The Case
A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait
abnormalities, neurogeni…
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - Over Not So Easy
July 1, 2006
Cucina R. Over Not So Easy. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/over-not-so-easy
The Case
A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On
admission, she reported allergies to a number of medications as well as a …
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Misread Label
November 1, 2003
Franklin BD. Misread Label. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/misread-label
The Case
An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine
[Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - Discharged Blindly
December 1, 2005
Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharged-blindly
The Case
An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to
receive enoxaparin (Lovenox) for self-administration at home…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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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…
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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…
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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…
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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…
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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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…