PSNet Weekly Update 4/18/2018
What's new in patient safety literature, news, & more.
Yang Y, Ward-Charlerie S, Dhavle AA, Rupp MT, Green J. J Manag Care Spec Pharm. 2018 Jan 18; [Epub ahead of print].
Martinez W, Pichert JW, Hickson GB, et al. J Patient Saf. 2018 Mar 15; [Epub ahead of print].
Pontefract SK, Hodson J, Slee A, et al. BMJ Qual Saf. 2018 Mar 23; [Epub ahead of print].
Haas S, Gawande A, Reynolds ME. JAMA. 2018 Apr 6; [Epub ahead of print].
Yeung S, Downing NL, Fei-Fei L, Milstein A. N Engl J Med. 2018;378:1271-1273.
Association of PeriOperatve Registered Nurses. AORN J. 2018;107:489-494.
NHS Improvement. London, UK: National Health Service; March 15, 2018.
Drug Enforcement Administration. April 28, 2018.
TeamSTEPPS Canada, Canadian Patient Safety Institute. May 8–9, 2018; Health Quality Council of Alberta, Calgary, Alberta, CAN.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Leah S. Karliner, MD, MAS, April 2018
Although the electronic health record noted that a woman required a Spanish interpreter to communicate with providers, no in-person interpreter was booked in advance. A non–Spanish-speaking physician attempted to use the clinic's phone interpreter services to communicate with the patient, but poor reception prevented the interpreter and patient from hearing each other. The patient called her husband, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. Fortunately, the physician was able to determine that the patient required further cardiac testing before proceeding with a planned elective surgery.
Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD, April 2018
A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.
Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD, April 2018
Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.
Expert viewpoints on current themes in patient safety.
Post-Hospital Syndrome, April 2018
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
Post-Hospital Syndrome, April 2018
Katherine Liang and Eric Alper, MD
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
IHI/NPSF Professional Learning Series Webcast. April 26, 2018; 12:00–1:00 PM (Eastern).
National Quality Forum. May 1, 2018; National Quality Forum, Washington, DC.
Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. Qual Saf Health Care. 2009;18:325-330.
Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.