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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - Vial Mistakes Involving Heparin
May 1, 2009
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
The Case
A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the
procedure, the surgeon re…
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - Moved Too Soon
Citation Text:
Lindenauer PK. Moved Too Soon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/web-mm/back-basics
July 13, 2010 - Back to Basics
Citation Text:
Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/node/849598/psn-pdf
May 31, 2023 - Remote Response Team and Customized Alert Settings
Help Improve Management of Sepsis
May 31, 2023
https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-
management-sepsis
Summary
Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Missed TB
Citation Text:
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/central-not-epidural
August 28, 2024 - Central, not Epidural
Citation Text:
Simmons D. Central, not Epidural. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Hazards of Loading Doses
Citation Text:
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33838/psn-pdf
July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary
Actions, and Complaints: What Do We Know?
July 1, 2017
Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We
Know? PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Falling Between the Cracks in the Software
Citation Text:
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
Citation Text:
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49521/psn-pdf
September 12, 2006 - A Troubling Amine
September 1, 2006
Flynn EA. A Troubling Amine. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/troubling-amine
The Case
A 43-year-old woman was admitted to the intensive care unit for symptoms of heart and respiratory failure.
She was found to have severe mitral and tricuspid valve regurgi…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - The Wrongful Resuscitation
April 1, 2008
Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrongful-resuscitation
The Case
An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and
poor quality of life had previously been r…
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…