PSNet Weekly Update 1/16/2019
What's new in patient safety literature, news, & more.
Aaron S, McEvoy DS, Ray S, Hickman TT, Wright A. J Am Med Inform Assoc. 2019;26:37-43.
Gaither JR, Shabanova V, Leventhal JM. JAMA Netw Open. 2018;1:e186558.
Lake ET, Roberts KE, Agosto PD, et al. J Patient Saf. 2018 Dec 28; [Epub ahead of print].
Fonarow GC. JAMA. 2018;320:2539-2541.
Sittig DF, Wright A, Coiera E, et al. Health Informatics J. 2018 Dec 11; [Epub ahead of print].
Dy CJ, Osei DA, Maak TG, et al. J Bone Joint Surg Am. 2018;100:1902-1911.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
NHS Improvement, National Health Service; London, UK: December 2018.
Society for Simulation in Healthcare. January 26–30, 2019; Henry B. González Convention Center, San Antonio, TX.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD, January 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).
Brian Clay, MD, January 2019
Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD, January 2019
Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.
Expert viewpoints on current themes in patient safety.
Audrey Lyndon, RN, PhD, 2018
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Rockville, MD: Agency for Healthcare Research and Quality; February 7, 2018. PA-15-180.
Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.
Millenson ML. Qual Saf Health Care. 2002;11:57-63.
Sentinel Event Alerts
Sentinel Event Alert. June 3, 2010;(45):1-3.
Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.