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PSNet: Patient Safety Network

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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.

PSNet Weekly Update 10/21/2020

What's new in patient safety literature, news, & more.
Study
Audiovisual
Commentary

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Spotlight Case
CE/MOC
Benjamin Stripe, MD, FACC, FSCAI and Dahlia Zuidema, Pharm.D, BC-ADM, CDCES ,  

A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessional care teams to coordinate management, and the importance of inter-team communication to identify issues and prevent poor outcomes. 

Multiple Levels Involved in Prescribing the Wrong Medication
Kristine Chin, PharmD, Van Chau, PharmD, Hannah Spero, MSN, APRN, and Jessamyn Phillips, DNP ,  

This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of phyiscians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification. 

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspective

This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.

Interview
George Edwin

Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.

Perspective

This Perspective differs from the typical Perspective in that it compiles findings and insights into a series of case studies from interviews and written responses from leaders at three different health systems who had to increase their telehealth capacities in response to the COVID-19 pandemic.

Did You Know?

Upcoming & Noteworthy

Meeting/Conference
Upcoming Meeting/Conference
TeamSTEPPS Master Training Course.
Armstrong Institute for Patient Safety and Quality.
Event Date
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