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

Journal Article

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

Armstrong N, Brewster L, Tarrant C, et al. Soc Sci Med. 2018;198:157-164.

Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis.

Meyer AND, Thompson PJ, Khanna A, et al. J Am Med Inform Assoc. 2018 Apr 20; [Epub ahead of print].

A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.

Hebbar KB, Colman N, Williams L, et al. Simul Healthc. 2018 Apr 30; [Epub ahead of print].

Management reasoning: beyond the diagnosis.

Cook CA, Sherbino J, Durning SJ. JAMA. 2018 May 10; [Epub ahead of print].

Newspaper/Magazine Article

How health care changes when algorithms start making diagnoses.

Burt A, Volchenboum S. Harv Bus Rev. May 8, 2018.

Surgical checklists save lives—but once in a while, they don't. Why?

Mukherjee S. New York Times Magazine. May 9, 2018.

Legislation/Regulation

World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.

Gelb AW, Morriss WW, Johnson W, et al; International Standards for a Safe Practice of Anesthesia Workgroup. Anesth Analg. 2018;126:2047-2055.

Tools/Toolkit

Medication Safety Dashboard.

National Health Service.

Meeting/Conference

The Joy Factor: Embracing Joy at Work to Improve Patient Safety and Ignite Passion and Productivity.

Midwest Alliance for Patient Safety. June 6–7, 2018; Chicago-Naperville Marriott Hotel, Naperville, IL.

Latest WebM&M Issue

Expert analysis of medical errors.

Out of Sight, Out of Mind: Out-of-Office Test Result Management

  • Spotlight Case
  • CME/CEU

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.

Root Cause Analysis Gone Wrong

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.

Suicide Risk in the Hospital

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.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Interview

In Conversation With… David Blumenthal, MD, MPP

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.

Interview

In Conversation With… John Halamka, MD, MS

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.

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Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

View All Primers

Did You Know?

Patient-perceived harm associated with care breakdowns.

Source

View All DYKs

Upcoming & Noteworthy

Canadian Patient Safety Officer Course.

Canadian Patient Safety Institute. May 28–31, 2018; The Westin, Ottawa, ON.

The 8th International Conference on Patient- and Family-Centered Care: Promoting Health Equity and Reducing Disparities.

Institute for Patient- and Family-Centered Care. June 11–13, 2018; Baltimore Marriott Waterfront Hotel, Baltimore, MD.

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Most Viewed

Study

Factors predictive of intravenous fluid administration errors in Australian surgical care wards.

Han PY, Coombes ID, Green B. Qual Saf Health Care. 2005;14:179-184.

Review

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

Study

Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.