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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…
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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.…
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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…
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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…
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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.…
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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…
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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…
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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
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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
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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
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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
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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
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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
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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
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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…
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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 …
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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…
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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…
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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…
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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…