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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…
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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…
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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…
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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 …
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Staggered Sensitivity Results
March 1, 2007
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results
The Case
A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck
dissection, and pectoralis fla…
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…