PSNet Weekly Update 5/23/2018
What's new in patient safety literature, news, & more.
Armstrong N, Brewster L, Tarrant C, et al. Soc Sci Med. 2018;198:157-164.
Meyer AND, Thompson PJ, Khanna A, et al. J Am Med Inform Assoc. 2018 Apr 20; [Epub ahead of print].
Hebbar KB, Colman N, Williams L, et al. Simul Healthc. 2018 Apr 30; [Epub ahead of print].
Cook CA, Sherbino J, Durning SJ. JAMA. 2018 May 10; [Epub ahead of print].
Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.
Mukherjee S. New York Times Magazine. May 9, 2018.
Gelb AW, Morriss WW, Johnson W, et al; International Standards for a Safe Practice of Anesthesia Workgroup. Anesth Analg. 2018;126:2047-2055.
National Health Service.
Midwest Alliance for Patient Safety. June 6–7, 2018; Chicago-Naperville Marriott Hotel, Naperville, IL.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Eric Poon, MD, MPH, May 2018
An elderly man with a history of giant cell arteritis (GCA) presented to the rheumatology clinic with recurrent headaches one month after stopping steroids. A blood test revealed that his C-reactive protein was elevated, suggesting increased inflammation and a flare of his GCA. However, his rheumatologist was out of town and did not receive the test result. Although the covering physician saw the result, she relayed just the patient's last name without the medical record number. Because the primary rheumatologist had another patient with the same last name, GCA, and a normal CRP, follow-up with the correct patient was delayed until his next set of blood tests.
Mohammad Farhad Peerally, MBChB, MRCP, and Mary Dixon-Woods, DPhil, May 2018
For a man with end-stage renal disease, a transplanted kidney was connected successfully. As the surgery was nearing completion, the surgeon instructed the anesthesiologist to give 3000 units of heparin. When preparing to close the incision, the clinicians noticed severe bleeding. The patient's blood pressure dropped, and transfusions were administered while they tried to stop the bleeding. The anesthesiologist mistakenly had administered 30,000 units of heparin. Although the surgical team administered protamine to reverse the anticoagulant effect, the bleeding and hypotension had irreversibly damaged the transplanted kidney.
Peter D. Mills, PhD, MS, May 2018
A woman with a history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department after a suicide attempt. Physical examination was significant for depressed affect and superficial lacerations to the bilateral forearms. Her left forearm laceration was sutured and bandaged with gauze. A psychiatrist evaluated her and placed an involuntary legal hold. Upon arrival to the inpatient psychiatric unit, the patient asked to use the bathroom. She unwrapped her wrist bandage, wrapped it around her neck and over the shower bar, and tried to hang herself. A staff member heard noise in the bathroom, immediately entered, and cut the gauze before the patient was seriously injured.
Expert viewpoints on current themes in patient safety.
A Decade After HITECH, May 2018
Dr. Blumenthal is President of the Commonwealth Fund and served as the National Coordinator for Health Information Technology from 2009-2011, during early implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the accompanying Meaningful Use program. We spoke with him about the HITECH Act and lessons learned in health care since it was enacted.
A Decade After HITECH, May 2018
Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information Officer of Beth Israel Deaconess Medical Center, and an emergency physician. He is widely known as one of the most thoughtful and provocative experts on the subject of health IT. We spoke with him about the HITECH Act and the consequences—anticipated and otherwise—of the digitization of health care.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Canadian Patient Safety Institute. May 28–31, 2018; The Westin, Ottawa, ON.
Institute for Patient- and Family-Centered Care. June 11–13, 2018; Baltimore Marriott Waterfront Hotel, Baltimore, MD.
Han PY, Coombes ID, Green B. Qual Saf Health Care. 2005;14:179-184.
Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.
Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.