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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Delayed Recognition of a Positive Blood Culture
July 1, 2017
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
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psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - Allergy to Holter
July 1, 2004
Williams M. Allergy to Holter. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/allergy-holter
The Case
A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4
the patient was sent to the cardiac clinic to start a continuous …
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psnet.ahrq.gov/node/49710/psn-pdf
May 01, 2014 - Discontinued Medications: Are They Really
Discontinued?
May 1, 2014
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
The Case
A 69-year-old man with a history of chronic atrial f…
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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Transfusion "Slip"
February 1, 2004
Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/transfusion-slip
The Case
A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma
center after a half-ton truck that had skidded out of control struck…
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/49585/psn-pdf
May 01, 2009 - Delirium or Dementia?
May 1, 2009
Rudolph JL. Delirium or Dementia? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/delirium-or-dementia
Case Objectives
State the key diagnostic differences between delirium and dementia.
Describe the Confusion Assessment Method for workup of suspected delirium.
Explain the…
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - The Perils of Contrast Media
June 1, 2017
Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/perils-contrast-media
Case Objectives
Recognize that contrast media are potentially nephrotoxic.
Identify key risk factors for the development of contrast-induced kidne…
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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/node/49405/psn-pdf
June 01, 2003 - XL or Smaller?
June 1, 2003
Kozer E. XL or Smaller? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/xl-or-smaller
The Case
With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3,
a 14-year-old boy presented to the emergency department with dehydration second…
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psnet.ahrq.gov/node/49717/psn-pdf
September 01, 2014 - A Lot of Pain (Medications)
September 1, 2014
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/lot-pain-medications
Case Objectives
Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids.
Describe the importance of understanding th…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/node/49802/psn-pdf
August 01, 2017 - Add-on Case and the Missing Checklist
August 1, 2017
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
The Case
A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic
data and ima…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/node/38474/psn-pdf
March 10, 2011 - Using computerized provider order entry and clinical
decision support to improve referring physicians'
implementation of consultants' medical
recommendations.
March 10, 2011
Were MC, Abernathy G, Hui SL, et al. Using computerized provider order entry and clinical decision
support to improve referring physicians' …
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psnet.ahrq.gov/node/39949/psn-pdf
October 27, 2010 - Patient safety and image transfer between referring
hospitals and neuroscience centres: could we do better?
October 27, 2010
Crocker M, Cato-Addison WB, Pushpananthan S, et al. Patient safety and image transfer between referring
hospitals and neuroscience centres: could we do better? Br J Neurosurg. 2010;24(4):391-…