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psnet.ahrq.gov/node/50931/psn-pdf
February 26, 2020 - Timely diagnosis of esophageal perforation
February 26, 2020
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
The Case
A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
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psnet.ahrq.gov/node/49530/psn-pdf
February 01, 2007 - Rapid Mis-St(r)ep
February 1, 2007
Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/rapid-mis-strep
The Case
A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F,
sore throat, and diffuse abdominal pain. There was no history…
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Cita…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
*
Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
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psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Disclosure of Medical Error
January 1, 2009
Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/disclosure-medical-error
Perspective
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts
advocate that greater discl…
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfusion Overload
1
2
Source and Credits
This presentation is based on the November 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
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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…
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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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…
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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…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/33844/psn-pdf
October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient
Safety
October 1, 2017
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
Perspective
Introduction
Health care–as…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…