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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Spotlight Case July 2008
Spotlight Case
All in the History
Source and Credits
This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
…
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
The Case
A 33-year-old woman with recently diagnosed acute …
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
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psnet.ahrq.gov/node/49447/psn-pdf
June 01, 2004 - Dangerous Dapsone
June 1, 2004
Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/dangerous-dapsone
The Case
A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the
emergency department with dyspnea. Upon admission, she was found to be hypo…
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - Bowel Injury After Laparoscopic Surgery
January 1, 2015
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
The Case
A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
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psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - CYP450 Drugs: Expect the Unexpected
April 1, 2014
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and
generalized anxiety …
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…