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  1. 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…
  2. 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…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49405/psn-pdf
    June 01, 2003 - XL or Smaller? June 1, 2003 Kozer E. XL or Smaller? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/xl-or-smaller The Case With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3, a 14-year-old boy presented to the emergency department with dehydration second…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49442/psn-pdf
    May 01, 2004 - Missed TB May 1, 2004 FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/missed-tb The Case A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory failure, and bilateral pulmonary infiltrates. She was treated empirically w…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49631/psn-pdf
    July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850362/psn-pdf
    June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49628/psn-pdf
    June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49791/psn-pdf
    April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49650/psn-pdf
    March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…
  10. 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…
  11. 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…
  12. 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…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49814/psn-pdf
    December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49449/psn-pdf
    June 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836942/psn-pdf
    April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49532/psn-pdf
    March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49659/psn-pdf
    July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49617/psn-pdf
    January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococc…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49587/psn-pdf
    May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49626/psn-pdf
    May 01, 2011 - Outbreak May 1, 2011 Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/outbreak The Case A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…

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