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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49389/psn-pdf
     February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49649/psn-pdf
     March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49542/psn-pdf
     August 21, 2007 - Copy and Paste August 21, 2007 Hersh WR. Copy and Paste. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/copy-and-paste The Case A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49745/psn-pdf
     October 01, 2015 - Amphotericin Toxicity October 1, 2015 Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/amphotericin-toxicity The Case A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral posaconazole for residual fungal disease. She present…

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49740/psn-pdf
     August 21, 2015 - Baffled by Botulinum Toxin August 21, 2015 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin The Case A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait abnormalities, neurogeni…

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49438/psn-pdf
     March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49471/psn-pdf
     December 01, 2004 - Carpe Diem (Seize the Day) December 1, 2004 Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day The Case A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic medical conditions including hypertension, h…

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49551/psn-pdf
     December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49515/psn-pdf
     July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49730/psn-pdf
     April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49842/psn-pdf
     September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49425/psn-pdf
     November 01, 2003 - Misread Label November 1, 2003 Franklin BD. Misread Label. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/misread-label The Case An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49496/psn-pdf
     December 01, 2005 - Discharged Blindly December 1, 2005 Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharged-blindly The Case An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home…

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49737/psn-pdf
     June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49525/psn-pdf
     December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49454/psn-pdf
     July 01, 2004 - Novel Drug Misuse July 1, 2004 Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/novel-drug-misuse Case Objectives Define the inclusion and exclusion criteria for patients in PROWESS. Understand why the FDA included APACHE score as an indication criterion for drotrec…

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49527/psn-pdf
     December 01, 2006 - Right Patient, Wrong Sample December 1, 2006 Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample The Case A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patien…

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49684/psn-pdf
     May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49547/psn-pdf
     October 01, 2007 - Code Blue—Where To? October 1, 2007 Adams BD. Code Blue—Where To? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/code-blue-where The Case An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxi…

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49419/psn-pdf
     October 01, 2003 - The Other Side October 1, 2003 Vincent CA. The Other Side. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/other-side Case Objectives List the factors contributing to wrong site surgery. Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surger…