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PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more.

Journal Article

Changes in prevalence of health care–associated infections in U.S. hospitals.

Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.

Bachelor's degree nurse graduates report better quality and safety educational preparedness than associate degree graduates.

Djukic M, Stimpfel AW, Kovner C. Jt Comm J Qual Patient Saf. 2018 Oct 15; [Epub ahead of print].

What we can do about maternal mortality—and how to do it quickly.

Mann S, Hollier LM, McKay K, Brown H. N Engl J Med. 2018;379:1689-1691.

Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention.

Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2018 Oct 18; [Epub ahead of print].

Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study.

Gopalan A, Mishra P, Alexeeff SE, et al. Diabet Med. 2018 Sep 3; [Epub ahead of print].

Managing alarm systems for quality and safety in the hospital setting.

Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.

Leveraging the continuum: a novel approach to meeting quality improvement and patient safety competency requirements across a large department of medicine.

Myers JS, Bellini LM. Acad Med. 2018;93:1321-1325.

Newspaper/Magazine Article

Why doctors hate their computers.

Gawande A. New Yorker. November 12, 2018.

Losing Laura.

DeMarco P. Globe Magazine. November 3, 2018.

How one hospital improved patient safety in 10 minutes a day.

van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.

Tools/Toolkit

Book/Report

A Patient-Safe Future.

Patient Safety Learning: London, UK; September 2018.

Latest WebM&M Issue

Expert analysis of medical errors.

Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees

  • Spotlight Case
  • CE/MOC

Olle ten Cate, PhD, November 2018

An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.

Written Signout: It Only Works If You Use The Right One

Kheyandra Lewis, MD, and Glenn Rosenbluth, MD, November 2018

Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.

Inadequate Preanesthetic Evaluation, Airway Trouble

Jeanna Blitz, MD, November 2018

When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Interview

In Conversation With… David Meltzer, MD, PhD

The Comprehensive Care Physician Model, November 2018

Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.

Perspective

The Comprehensivist Model of Care: A Hospitalist's View

The Comprehensive Care Physician Model, November 2018

Robert Wachter, MD

This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.

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Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

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Did You Know?

Barriers to patients speaking up about care concerns in the ICU.

Source

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Upcoming & Noteworthy

Armstrong Institute for Patient Safety and Quality Observership.

Armstrong Institute for Patient Safety and Quality. November 27–29, 2018; Johns Hopkins Hospital, Baltimore, MD.

Building Reliability With Safety Huddles.

Institute for Healthcare Improvement. November 27, 2018–January 22, 2019.

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Most Viewed

Study

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.

Study

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

Newspaper/Magazine Article

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

ISMP Medication Safety Alert! Acute Care Edition. January 28, 2016;21:1-4. February 11, 2016;21:1-5.