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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/49436/psn-pdf
February 26, 2004 - Transfusion "Slip"
February 1, 2004
Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/transfusion-slip
The Case
A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma
center after a half-ton truck that had skidded out of control struck…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/49401/psn-pdf
May 01, 2003 - Suicidal Man With Gun
May 1, 2003
Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/suicidal-man-gun
The Case
The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe
depression that had persisted for nearly 2 years. On initial inter…
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/node/49691/psn-pdf
September 01, 2013 - DRESSed for Failure
September 1, 2013
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dressed-failure
The Case
A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand
cellulitis and an uncomplicated urinary tract infec…
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psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Operationalizing Patient Safety at Academic Medical
Centers
August 1, 2010
Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
Perspective
Academic medical…
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
-
psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Preventing PICC Complications: Whose Line Is It?
December 1, 2012
Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
The Case
A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - Not necessarily in severe ways,
but through the kinds of behaviors that frontline caregivers perceive … If you don't have equally transparent and equitable ways of judging and moving those
situations into … demonstrate that no matter
how you're paid, if you understand how you're paid, you can focus these tools in ways
-
psnet.ahrq.gov/node/38108/psn-pdf
September 30, 2014 - No more blame & shame: developing event-reporting
systems may go a long way to reducing patient care
errors in EMS.
September 30, 2014
Rajasekaran K, Fairbanks RJ, Shah M. No more blame & shame. Developing event-reporting systems may
go a long way to reducing patient care errors in EMS. EMS magazine. 2008;37(9):61…
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psnet.ahrq.gov/node/41018/psn-pdf
December 21, 2011 - What stands in the way of technology-mediated patient
safety improvements? A study of facilitators and barriers
to physicians' use of electronic health records.
December 21, 2011
Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of
facilitators and barriers to physician…
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psnet.ahrq.gov/node/46279/psn-pdf
August 02, 2017 - Recognizing the ordinary as extraordinary: insight into
the "way we work" to improve patient safety outcomes.
August 2, 2017
Henneman EA. Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve
Patient Safety Outcomes. Am J Crit Care. 2017;26(4):272-277. doi:10.4037/ajcc2017812.
https:…
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psnet.ahrq.gov/node/47230/psn-pdf
August 15, 2018 - Experience feedback committees: a way of implementing
a root cause analysis practice in hospital medical
departments.
August 15, 2018
François P, Lecoanet A, Caporossi A, et al. Experience feedback committees: A way of implementing a
root cause analysis practice in hospital medical departments. PLoS One. 2018;13(7…
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psnet.ahrq.gov/node/43744/psn-pdf
December 03, 2014 - Mobile physician reporting of clinically significant
events—a novel way to improve handoff communication
and supervision of resident on call activities.
December 3, 2014
Nabors C, Peterson SJ, Aronow WS, et al. Mobile physician reporting of clinically significant events-a novel
way to improve handoff communication…