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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49726/psn-pdf
     March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49854/psn-pdf
     February 01, 2019 - Diagnostic Failure: The Growing Deficit February 1, 2019 Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit The Case A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49796/psn-pdf
     June 01, 2017 - Chest Tube Complications June 1, 2017 Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/chest-tube-complications The Case A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a spontaneous left pneumothorax (coll…

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49761/psn-pdf
     May 01, 2016 - The Fluidity of Diagnostic "Wet Reads" May 1, 2016 Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads The Case A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain. His electroc…

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49683/psn-pdf
     April 01, 2013 - Acute Care Admission of the Behavioral Health Patient April 1, 2013 Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient The Case A 25-year-old man presented to the emergency department (E…

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49413/psn-pdf
     September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49595/psn-pdf
     December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49463/psn-pdf
     October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49838/psn-pdf
     August 01, 2018 - An Untimely End Despite End-of-Life Care Planning August 1, 2018 Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning The Case A 76-year-old man was admitted to the intensive care unit (…

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49850/psn-pdf
     January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…

471. Communication With Consultants | PSNet
     psnet.ahrq.gov/web-mm/communication-consultants
     October 01, 2018 - Communication With Consultants Citation Text: Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49750/psn-pdf
     January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49503/psn-pdf
     February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49488/psn-pdf
     August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49781/psn-pdf
     January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49435/psn-pdf
     February 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49634/psn-pdf
     September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49506/psn-pdf
     March 01, 2006 - The Wet Read March 1, 2006 Arenson RL. The Wet Read. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/wet-read Case Objectives Appreciate the limitations of radiology resident emergency coverage. Understand the rate of discrepancy between radiology resident preliminary reads and attending radiologists' fina…

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49807/psn-pdf
     October 01, 2017 - Translating From Normal to Abnormal October 1, 2017 Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/translating-normal-abnormal Case Objectives Define limited English proficiency. Understand the principal approaches to machine translation. Review the way mach…

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49834/psn-pdf
     July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…