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381. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49459/psn-pdf
     September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49646/psn-pdf
     February 01, 2012 - Poorly Advanced Directives February 1, 2012 Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/poorly-advanced-directives The Case Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions described his overall health as decli…

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49610/psn-pdf
     October 01, 2010 - "Recurrent" Appendicitis October 1, 2010 Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/recurrent-appendicitis The Case An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On physical examination, the patient showed rebound t…

384. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49817/psn-pdf
     January 01, 2018 - Slow Down: Right Drug, Wrong Formulation January 1, 2018 Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation The Case A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49504/psn-pdf
     March 01, 2006 - Liposuction Gone Awry March 1, 2006 Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/liposuction-gone-awry The Case A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s office, he underwent neck and facial liposuction wit…

386. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49778/psn-pdf
     December 01, 2016 - One Dose, Two Errors December 1, 2016 Filice GA. One Dose, Two Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/one-dose-two-errors The Case A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory failure secondary to community-acquired pneumonia. The pati…

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49789/psn-pdf
     April 01, 2017 - Engaging Seriously Ill Older Patients in Advance Care Planning April 1, 2017 Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning Case Objectives Define advance care planning an…

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49498/psn-pdf
     January 01, 2006 - An Ounce of Prevention January 1, 2006 Kucher N. An Ounce of Prevention. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/ounce-prevention Case Objectives Assess risk for venous thromboembolism (VTE) in hospitalized patients List recommended strategies for VTE prevention for various risk groups Identify pat…

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49651/psn-pdf
     May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…

390. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49648/psn-pdf
     March 01, 2012 - Postdischarge Follow-Up Phone Call March 1, 2012 Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call Case Objectives Understand why preventing readmissions through postdischarge phone calls is important. Describe evidence su…

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49758/psn-pdf
     April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49810/psn-pdf
     November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49765/psn-pdf
     August 21, 2016 - Cognitive Overload in the ICU August 21, 2016 Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/cognitive-overload-icu Case Objectives Identify the role of cognitive overload—especially interruptions—in compromising quality of care and patient safety. List…

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49723/psn-pdf
     January 01, 2015 - Monitoring Fetal Health January 1, 2015 Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/monitoring-fetal-health Case Objectives Define fetal heart rate monitoring. Describe the current state of evidence regarding fetal heart rate monitoring. List the known …

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49566/psn-pdf
     July 01, 2008 - What Was in Those Platelets? July 1, 2008 Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/what-was-those-platelets The Case A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well without complications, and postoperativel…

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49849/psn-pdf
     January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49721/psn-pdf
     December 01, 2014 - Ebola: Are We Ready? December 1, 2014 Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/ebola-are-we-ready The Case A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting,…

398. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49478/psn-pdf
     April 01, 2005 - Compare and Contrast April 1, 2005 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/compare-and-contrast Case Objectives Define contrast nephropathy (CN) List risk factors for CN Implement pharmacologic strategies for CN prophylaxis Follow an algorithm for CN risk …

399. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49624/psn-pdf
     May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49388/psn-pdf
     February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …