PSNet Weekly Update 9/19/2018
What's new in patient safety literature, news, & more.
Bickmore TW, Trinh H, Olafsson S, et al. J Med Internet Res. 2018;20:e11510.
Upadhyay S, Weech-Maldonado R, Lemak CH, Stephenson A, Mehta T, Smith DG. Health Care Manage Rev. 2018 Aug 28; [Epub ahead of print].
Panagioti M, Geraghty K, Johnson J, et al. JAMA Intern Med. 2018 Sep 4; [Epub ahead of print].
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
Arbaje AI, Hughes A, Werner N, et al. BMJ Qual Saf. 2018 Jul 17; [Epub ahead of print].
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
Special or Theme Issue
Cunha CB, ed. Med Clin North Am. 2018;102:797-976.
Schulte F, Lucas E, Mahr J. Kaiser Health News and Chicago Tribune. September 5, 2018.
Howley EK. US News & World Report. September 5, 2018.
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
Society to Improve Diagnosis in Medicine.
National Academy of Medicine. October 1, 2018; Keck Center of the National Academies, Washington, DC.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
David J. Lucier, MD, MBA, MPH, and Jeffrey L. Greenwald, MD, September 2018
An older woman with lung cancer that had metastasized to the brain was admitted to the hospital and found to have Pneumocystis jiroveci pneumonia (PJP pneumonia), invasive pulmonary aspergillus, diffuse myopathy, and gastrointestinal bleeding. Medication reconciliation revealed that she had been prescribed a high dose of dexamethasone to reduce the brain swelling associated with the cancer. Although the intention had been to taper the steroids after she received radiotherapy for her brain metastases, the corticosteroids were never tapered, and she continued to take high-dose steroids for more than 2 months. Physicians believed that all of her acute issues were a result of the mistakenly high dose of the steroids.
Jason Bergsbaken, PharmD, September 2018
A woman with cancer was admitted to begin a chemotherapy cycle of IV etoposide (daily for 3 days) and IV cisplatin (single dose). At the hospital's cancer center satellite pharmacy, the pharmacist entered the order into the computer and prepared the first dose of the medications. While transcribing the order, the pharmacist inadvertently switched the duration of therapy for the two agents. The transposition did not affect the patient's first day of therapy. The second day fell on a Saturday, when the satellite pharmacy was closed; a different pharmacist who did not have access to the original chemotherapy order prepared the therapy order. Cisplatin was labeled, dispensed, and reached the bedside. The nurse bypassed the double-check policy for verifying the order prior to administration, and the patient received the second dose of cisplatin instead of the intended dose of etoposide.
Jessica Katznelson, MD, September 2018
In a simulated cardiac resuscitation case of a 5-year-old boy found pulseless and apneic in the bathtub by a parent, many interprofessional teams had difficulty with resuscitation due to a lack of interoperability between the prestocked disposable laryngoscope blades and handles on the Broselow cart (a proprietary system designed to facilitate finding appropriate-sized equipment for pediatric patients requiring lifesaving interventions) with the emergency department's actual stock of blades and handles. This incompatibility led to significant delays and some failures to intubate. Teams often did not recognize the incompatibility and spent unnecessary time replacing batteries while others called for backup airway teams.
Expert viewpoints on current themes in patient safety.
Patient Engagement, September 2018
Professor Lawton is Director of the Yorkshire and Humber Patient Safety Translational Research Center, a Professor in the Psychology of Healthcare at the University of Leeds, and a health psychologist who conducts research on human factors and patient involvement in patient safety. We spoke with her about her experience with patient engagement and insights gleaned from her research.
Patient Engagement, September 2018
Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess Medical Center, and Associate Professor of Medicine at Harvard Medical School. Her research focuses on transparency in health care delivery systems and partnering with patients to improve health care. We spoke with her about patient engagement and her experience with the OpenNotes project.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Institute for Safe Medication Practices. September 26, 2018; 11:00 AM–12:00 PM (Eastern).
Institute for Healthcare Improvement and Hospital Israelita Albert Einstein. October 3–5, 2018; Hotel Hilton, Cartagena de Indias, Colombia.
The Joint Commission and National Quality Forum.
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.
Coombes R. BMJ Podcast. June 1, 2012.
Snyderman N. NBC News. February 22, 2012.