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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49607/psn-pdf
    August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33884/psn-pdf
    July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49823/psn-pdf
    March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure March 1, 2018 Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure The Case An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
  8. psnet.ahrq.gov/web-mm/over-not-so-easy
    April 01, 2005 - Over Not So Easy Citation Text: Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49837/psn-pdf
    August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49641/psn-pdf
    November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget Something? November 1, 2011 Lubel J. Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something The Case A 51-year-old Cantonese-speaking female with a his…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49784/psn-pdf
    February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50842/psn-pdf
    January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49736/psn-pdf
    June 01, 2015 - Inflicting Confusion June 1, 2015 Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/inflicting-confusion The Case A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with acute-onset abdominal pain, nausea, vomiting, an…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49401/psn-pdf
    May 01, 2003 - Suicidal Man With Gun May 1, 2003 Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/suicidal-man-gun The Case The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. On initial inter…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49637/psn-pdf
    October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49718/psn-pdf
    January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…