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PSNet: Patient Safety Network

Welcome to PSNet

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

PSNet Weekly Update 1/20/2021

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

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
Code Status vs. Care Status
Spotlight Case
CE/MOC
Rebecca K. Krisman, MD, MPH and Hannah Spero, MSN, APRN, NP-C ,  

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Although no timeline for the transfer had been established, the patient’s code status was changed to “Do Not Resuscitate” (DNR) with a plan for him to remain in the ICU for a few days to stabilize. Unfortunately, the patient was transferred out of the ICU after the palliative care team left for the weekend and his respiratory status deteriorated. The patient died in the hospital later that week; he was never able to go home as he had wished. The associated commentary describes how care inconsistent with patient goals and wishes is a form of preventable harm, discusses the need for clear communication between care team, and the importance of providers and healthcare team members serving as advocates for their vulnerable patients.

Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability
Karen Semkiw, RN-C, MPA, Dua Anderson, MD, MS, and JoAnne Natale, MD, PhD ,  

 A 3-month-old male infant, born at 26 weeks’ gestation with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was readmitted for abdominal distension and constipation. He was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis and an urgent exploratory laparotomy was scheduled for suspected obstruction. The PICU team determined that the patient was stable for brief transport from the PICU to the operating room (OR). During intrahospital transport, the patient had two bradycardic episodes – the first self-resolved but the second necessitated chest compressions and intubation. The patient was rapidly moved to the OR where return of spontaneous circulation occurred within five minutes. The associated commentary describes the risks associated with intrahospital transport (particularly among pediatric patients) and critical processes that should be put in place to mitigate these risks via clear communication and structured decision-making among the intrahospital transport team. 

Delayed Breast Cancer Diagnosis: A False Sense of Security.
Saul N. Weingart, MD, MPP, PhD, Gordon D. Schiff MD, and Ted James, MD, FACS ,  

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy. Confusion regarding biopsy scheduling led to delays and, 7 months after initial presentation, the patient was diagnosed with invasive breast cancer involving the axillary nodes and spine. The commentary discusses the diagnostic challenges of potentially discordant findings between imaging and physical exams and the importance of structured inter-professional handoffs and closed-loop referrals in reducing diagnostic delays and associated harm. 

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspective

This piece discusses prevalent adverse events in dental care and the challenges in identifying these patient safety events.

Interview
Muhammad Walji

Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.   

Interview
Katie Suda

Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medicine in the Division of General Internal Medicine. She is a pharmacist by training with a specialty in infectious diseases and a research concentration in the area of dental antibiotic and opioid stewardship. We discussed antibiotic and opioid prescribing in dental care and challenges for implementing stewardship programs.

Did You Know?

Upcoming & Noteworthy

Meeting/Conference
Upcoming Meeting/Conference
TeamSTEPPS Master Trainer Course.
AHA Training. February 1-March 31, 2021.
Event Date
-
Audiovisual
Audiovisual Presentation
ISMP Medication Safety Intensive.
Institute for Safe Medication Practices. February 25-26, 2021
Event Date
-

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