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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

Defining and measuring diagnostic uncertainty in medicine: a systematic review.

Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. J Gen Intern Med. 2017 Sep 21; [Epub ahead of print].

Patients' experiences with communication-and-resolution programs after medical injury.

Moore J, Bismark M, Mello MM. JAMA Intern Med. 2017 Oct 9; [Epub ahead of print].

Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative.

Smith SN, Greene MT, Mody L, Banaszak-Holl J, Petersen LD, Meddings J. BMJ Qual Saf. 2017 Sep 26; [Epub ahead of print].

The business case for investing in physician well-being.

Shanafelt T, Goh J, Sinsky C. JAMA Intern Med. 2017 Sep 25; [Epub ahead of print].

Delirium in hospitalized older adults.

Marcantonio EP. N Engl J Med. 2017;377:1456-1466.

Public reporting of surgical outcomes: surgeons, hospitals, or both?

Jha AK. JAMA. 2017 Sep 28; [Epub ahead of print].

Audiovisual

Opioid addiction is the biggest drug epidemic in U.S. history. How'd we get here?

William Brangham. PBS News Hour. September 29, 2017.

Book/Report

The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety.

Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.

Surgical Patient Safety: A Case-Based Approach.

Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631.

Newspaper/Magazine Article

Web Resource

Pressure Injury Prevention in Hospitals Training Program.

Rockville, MD: Agency for Healthcare Research and Quality; September 2017.

Latest WebM&M Issue

Expert analysis of medical errors.

Translating From Normal to Abnormal

  • Spotlight Case
  • CME/CEU

Anne M. Turner, MD, MLIS, MPH, October 2017

A Spanish-speaking woman presented to an urgent care clinic complaining of headache and worsening dizziness, for which the treating clinician ordered an MRI. When the results came in with no concerning findings later that day, the provider used Google Translate to write a letter informing the patient of the results. The patient interpreted the letter to mean that the results were concerning. This miscommunication led to patient distress and extra visits to both urgent care and the emergency department.

High-Risk Medications, High-Risk Transfers

Nancy Staggers, PhD, RN, October 2017

Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.

Hyperbilirubinemia Refractory to Phototherapy

Vinod K. Bhutani, MD, and Ronald J. Wong, October 2017

A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Interview

In Conversation With… Jeffrey Starke, MD

Presenteeism: A Patient Safety Challenge, October 2017

Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and previously served as Infection Control Officer at Texas Children's Hospital. We spoke with him about "presenteeism" (coming to work while ill) in health care and its impact on provider and patient safety.

Perspective

Health Care Worker Presenteeism: A Challenge for Patient Safety

Presenteeism: A Patient Safety Challenge, October 2017

Julia E. Szymczak, PhD

This piece explores the risks of presenteeism among health care workers and factors, such as cultural expectations, that contribute to its occurrence.

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Patient Safety Primers

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

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Did You Know?

Clinicians' recommended solutions for delayed diagnosis in primary care.

Source

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Upcoming & Noteworthy

2017 Hospital Quality Institute Conference.

Hospital Quality Institute. November 1–3, 2017, Monterey Marriott and Monterey Conference Center, Monterey, CA.

Anesthesia Patient Safety Foundation (APSF) Grant Program.

Indianapolis, IN: Anesthesia Patient Safety Foundation.

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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.

Commentary

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.