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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49800/psn-pdf
    July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49539/psn-pdf
    June 01, 2007 - Informed or Misled? June 1, 2007 White SM. Informed or Misled? . PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/informed-or-misled The Case A 50-year-old man arrived at the hospital for an elective total knee replacement. Based on preoperative discussions, the patient expected to receive spinal anesthesia.…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49652/psn-pdf
    May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49588/psn-pdf
    August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care August 1, 2009 Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care Case…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49633/psn-pdf
    September 01, 2011 - The Safety and Quality of Long Term Care September 1, 2011 Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care Case Objectives Identify commonly reported adverse events in long-term care. Identify two to three challenges…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49501/psn-pdf
    February 03, 2006 - Lost in Transition February 1, 2006 Beach C. Lost in Transition. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/lost-transition Case Objectives Provide an overview of transitions in continuously operating industries Review cognitive error Describe the complex dynamics of transitions in emergency care Pro…
  8. psnet.ahrq.gov/issue/enhancing-patient-safety-prehospital-environment-analyzing-patient-perspectives-non-transport
    September 20, 2017 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
  9. psnet.ahrq.gov/issue/critical-errors-infrequently-performed-trauma-procedures-after-training
    June 27, 2018 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
  10. psnet.ahrq.gov/issue/risk-factors-adverse-events-emergency-department-procedural-sedation-children
    January 19, 2014 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
  11. psnet.ahrq.gov/issue/color-coded-prefilled-medication-syringes-decrease-time-delivery-and-dosing-errors-simulated
    September 09, 2015 - paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference
  12. psnet.ahrq.gov/issue/emergency-medical-services-provider-perceptions-nature-adverse-events-and-near-misses-out
    September 09, 2010 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
  13. psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical-incident
    July 27, 2016 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
  14. psnet.ahrq.gov/issue/who-gets-benefit-doubt-performance-evaluations-medical-errors-and-production-gender
    May 01, 2012 - prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49848/psn-pdf
    January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble November 1, 2018 Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble The Case Case #1: A 34-year-old woman was scheduled for a hysteroscopy under g…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49643/psn-pdf
    December 01, 2011 - More Treatment—Better Care? December 1, 2011 Redberg R. More Treatment—Better Care? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/more-treatment-better-care The Case The patient is a 27-year-old female who presented to a 250-bed community hospital with numbness and tingling of her hands and feet. She was …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49417/psn-pdf
    October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - Eptifibatide Epilogue April 1, 2009 Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue The Case A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute coronary syndrome. Serial testing for mark…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49529/psn-pdf
    February 01, 2007 - Crossed Coverage February 1, 2007 Kayser SR. Crossed Coverage. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/crossed-coverage The Case A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation. She had already undergone multiple surgeries, including…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49535/psn-pdf
    May 01, 2007 - Production Pressures May 1, 2007 Carayon P. Production Pressures. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/production-pressures The Case A 65-year-old man with bipolar disorder was scheduled for maintenance electroconvulsive therapy (ECT), a procedure he had received dozens of times before. These pro…

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