PSNet Weekly Update 3/21/2018
What's new in patient safety literature, news, & more.
Vivolo-Kantor AM, Seth P, Gladden RM, et al. MMWR Morb Mortal Wkly Rep. 2018;67:279-285.
Shah T, Patel-Teague S, Kroupa L, Meyer AND, Singh H. BMJ Qual Saf. 2018 Mar 5; [Epub ahead of print].
Davis J, Harrington N, Bittner Fagan H, Henry B, Savoy M. J Am Board Fam Med. 2018;31:113-125.
Stoklosa H, Scannell M, Ma Z, Rosner B, Hughes A, Bohan JS. Emerg Med J. 2018 Feb 3; [Epub ahead of print].
Dynan L, Goudie A, Brady PW. J Healthc Qual. 2018;40:69-78.
Melnyk BM, Orsolini L, Tan A, et al. J Occup Environ Med. 2018;60:126-131.
Joint Commission. March 12, 2018.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Disability Law Center. Boston, MA: February 2018.
Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Anna Parks, MD, and Margaret C. Fang, MD, MPH , March 2018
One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.
Stephen Bacak, DO, MPH, and Loralei Thornburg, MD, March 2018
A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.
Robert E. O'Connor, MD, MPH, March 2018
Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.
Expert viewpoints on current themes in patient safety.
Nursing and Patient Safety, March 2018
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
Nursing and Patient Safety, March 2018
Jane Ball, PhD, and Peter Griffiths, PhD
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Human Factors and Ergonomics Society. March 26–28, 2018; Marriott Copley Place, Boston, Massachusetts.
Armstrong Institute for Patient Safety and Quality. April 3, 2018; Constellation Energy Building Conference Center, Baltimore, MD.
Elnour AA, Ellahham NH, Al Qassas HI. Pharm World Sci. 2008;30:182-190.
Ryan J. KUOW. National Public Radio. August 1, 2013.
Washington, DC: Commission on Care; June 2016.