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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49732/psn-pdf
    May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49602/psn-pdf
    April 01, 2010 - Anticoagulation: Held Too Long April 1, 2010 Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long The Case A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with abdominal pain. Because of the…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865376/psn-pdf
    March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures March 27, 2024 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49455/psn-pdf
    July 01, 2004 - The Worst Headache July 1, 2004 Edlow JA. The Worst Headache. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/worst-headache The Case A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient clinic with a 4-day history of headache. While shopping 4 days earlier, …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846768/psn-pdf
    March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. March 29, 2023 Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery The Ca…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49408/psn-pdf
    July 01, 2003 - Check the Wristband July 1, 2003 Rosenthal M. Check the Wristband. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-wristband The Case The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the impending surgery. The patient spoke English and appeared to be of aver…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49552/psn-pdf
    January 01, 2008 - How Do Providers Recover From Errors? January 1, 2008 West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors Case Objectives Describe the provider-specific prevalence of medical errors. Appreciate the impact of medical errors on care pr…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60857/psn-pdf
    August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49549/psn-pdf
    December 06, 2007 - Elopement December 1, 2007 Gerardi D. Elopement. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/elopement Case Objectives Define elopement and differentiate it from wandering and leaving against medical advice. Identify leading contributors to elopement events. Describe strategies for preventing elopement…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49480/psn-pdf
    May 01, 2005 - Diagnosing Diagnostic Mistakes May 1, 2005 McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes Learning Objectives Understand the biases that may contribute to overcalling medical errors Describe the impact of conside…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49828/psn-pdf
    May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867475/psn-pdf
    February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient February 26, 2025 Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49550/psn-pdf
    December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? December 1, 2007 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals The Case …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49558/psn-pdf
    April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad April 1, 2008 Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad Case Objectives Understand the indications for antibiotic treatment in …

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