PSNet Weekly Update 2/13/2019
What's new in patient safety literature, news, & more.
Chen Q, Larochelle MR, Weaver DT, et al. JAMA Netw Open. 2019;2:e187621.
Reinhardt H, Otte P, Eggleton AG, et al. Cancer. 2019 Jan 29; [Epub ahead of print].
Ratwani RM, Reider J, Singh H. JAMA. 2019 Feb 4; [Epub ahead of print].
Dixon-Woods M. Clin Med (Lond). 2019;19:47-56.
Driver BE, Scharber SK, Fagerstrom ET, Klein LR, Cole JB, Dhaliwal RS. J Emerg Med. 2019;56:109-113.
Trowbridge RL, Reilly JB, Clauser JC, Durning SJ. Diagnosis (Berl). 2018;5:229-233.
Horn SR, Liu TC, Horowitz JA, et al. Spine (Phila Pa 1976). 2018;43:E1358-E1363.
Shouhed D, Beni C, Manguso N, IsHak WW, Gewertz BL. JAMA Surg. 2019 Jan 30; [Epub ahead of print].
Span P. New York Times. February 1, 2019.
Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.
Washington Patient Safety Coalition. WPSC Lunchtime Webinar Series. February 21, 2019, 2:00 PM (Eastern).
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Stephanie Mueller, MD, MPH, February 2019
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.
Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD, February 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Robert Chang, MD, and Scott Flanders, MD, February 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.
Expert viewpoints on current themes in patient safety.
Teaching Patient Safety, February 2019
Dr. Skochelak is the Group Vice President for Medical Education at the American Medical Association (AMA). She leads the AMA's Accelerating Change in Medical Education initiative, which aims to align physician training with the changing needs of our health care system. We spoke with her about her experience in medical education.
Teaching Patient Safety, February 2019
Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc
This piece spotlights the need for educational and cultural transformation to achieve sustainable progress in patient outcomes and health.
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. RFA-HS-19-001.
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
Miller A, Moon B, Anders S, Walden R, Brown S, Montella D. Int J Med Inform. 2015;84:1009-1018.
DukeMed News [serial online]. January 8, 2005.
Leistikow IP, Kalkman CJ, Bruijn H. BMJ. 2011;342:d3447.