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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. 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…
  5. 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: …
  6. Psn-Pdf (pdf file)

    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 …
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. 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 …
  10. 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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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…
  16. 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…
  17. Psn-Pdf (pdf file)

    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,…
  18. Psn-Pdf (pdf file)

    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…
  19. 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…
  20. Psn-Pdf (pdf file)

    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…

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