PSNet Weekly Update 8/15/2018
What's new in patient safety literature, news, & more.
Mossburg SE, Dennison Himmelfarb C. J Patient Saf. 2018 Jun 25; [Epub ahead of print].
Rosenbluth G, Destino LA, Starmer AJ, et al. Pediatr Qual Saf. 2018 Jul 20; [Epub ahead of print].
Copi EJ, Kelley LR, Fisher KK. J Am Pharm Assoc (2003). 2018;58(suppl 4):S46-S50.
Lyndon A, Malana J, Hedli LC, Sherman J, Lee HC. J Obstet Gynecol Neonatal Nurs. 2018;47:324-332.
François P, Lecoanet A, Caporossi A, Dols AM, Seigneurin A, Boussat B. PLoS One. 2018;13:e0201067.
Young M, Thomas A, Lubarsky S, et al. Acad Med. 2018;93:990-995.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. August 2, 2018. Publication No. NOT-HS-18-015.
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
Fox ER. Am J Health Syst Pharm. 2018 Jul 30; [Epub ahead of print].
September 17, 2018; Coalition for Patient Safety, German Federal Ministry of Health, Berlin, DE.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Jeffrey Jim, MD, MPHS, August 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
Giovanni Elia, MD; Susan Barbour, RN, MS; and Wendy G. Anderson, MD, MS, August 2018
Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members. Another nurse found the canceled orders, thought it was an error, and asked another physician (who was also unaware of the change in plans) to reinstate the orders. The patient was extubated and died a few hours later.
Helen Pervanas, PharmD, RPh, and David VanValkenburgh, August 2018
Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.
Expert viewpoints on current themes in patient safety.
Update on Simulation, August 2018
Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthesiology, Biomedical Informatics, and Medical Education at Vanderbilt University. He holds the Norman Ty Smith Chair in Patient Safety and Medical Simulation. We spoke with him about the current state of simulation training in health care, barriers to progress, and potential innovations.
Update on Simulation, August 2018
Joseph O. Lopreiato, MD, MPH
This piece explores health care simulation including the four main methods used and the evidence base for its impact on learning and patient care.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Society to Improve Diagnosis in Medicine and Patient Safety Switzerland. August 30–31, 2018, Inselspital University Hospital, Bern, Switzerland.
Anesthesia Patient Safety Foundation. September 5–6, 2018; Royal Palms Resort and Spa, Phoenix, AZ.
Horsham, PA: Institute for Safe Medication Practices; July 26, 2018.
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. Qual Saf Health Care. 2009;18:325-330.
Rozmovits L, Mior S, Boon H. BMC Complement Altern Med. 2016;16:164.
Elnour AA, Ellahham NH, Al Qassas HI. Pharm World Sci. 2008;30:182-190.