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PSNet: Patient Safety Network

Welcome to PSNet

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

PSNet Weekly Update 6/16/2021

What's new in patient safety literature, news, & more.
Study
Commentary
Review
Upcoming Meeting/Conference
Press Release/Announcement

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
An Inadvertent Bolus of Norepinephrine.
Spotlight Case
CE/MOC
Sarina Fazio, PhD, RN, Emma Blackmon, PhD, RN, Amy Doroy, PhD, RN, Ai Nhat Vu and Paul MacDowell, PharmD. ,  

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated. The error was recognized after 15 minutes of infusion, but the patient had ongoing hypotension following the inadvertent bolus. The commentary summarizes the common errors associated with administration of multiple intravenous infusions in intensive care settings and gives recommendations for reducing errors associated with co-administration of infusions.

Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
Jeremiah Duby, PharmD, Kendra Schomer, PharmD, Victoria Oyewole, PharmD, Delia Christian, RN, BSN, CNRN, and Sierra Young, PharmD,  

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7. A continuous intravenous (IV) infusion of norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure goal of greater than 85 mmHg. Unfortunately, norepinephrine was incorrectly programmed into the infusion pump for a weight-based dose of 0.5 mcg/kg/min rather than the ordered dose of 0.5 mcg/min, resulting in a dose that was 70 times greater than intended. The patient experienced bradycardia and cardiac arrest and subsequently died.

Hyponatremia Secondary to Home Parenteral Nutrition Error
Kelly Haas, MD, and Andrew Lee, PharmD,  

A 4-year-old (former 33-week premature) boy with a complex medical history including gastroschisis and subsequent volvulus in infancy resulting in short bowel syndrome, central venous catheter placement, and home parenteral nutrition (PN) dependence was admitted with hyponatremia. A pharmacist from the home infusion pharmacy notified the physician that an error in home PN mixing had been identified; a new file had been created for this chronic PN patient by the home infusion pharmacy and the PN formula in this file was transcribed erroneously without sodium acetate. This error resulted in only 20% of the patient’s prescribed sodium being mixed into the home PN solution for several weeks, resulting in hyponatremia and unnecessary hospital admission. The commentary highlights the importance of collaboration between clinicians and patients’ families for successful home PN and the roles of communication process maps, standardizing PN compounding, and order verification in reducing the risk of medication error.

The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers
Katherine Glaser, MD, MPH, and Joy Vongspanich Dray, PharmD, BCACP, AAHIVP ,  

A healthy 53-year-old man presented for sexually transmitted infection (STI) screening after being informed by the health department that he had sexual intercourse with a male partner who was recently diagnosed with and treated for syphilis. He acknowledged having unprotected sex with male partners, reported no history of syphilis or Human Immunodeficiency Virus (HIV), and denied any penile lesions, discharge, or rash. Rapid plasma reagin (RPR) and Treponema pallidum particle agglutination (TPPA) assays were ordered, but the results were not reviewed. No futher testing or physical examination occurred; he was treated with one intramuscular dose of penicillin and no further follow-up was indicated. Two years later, the patient presented to his primary care provider (PCP) with symptoms of neurosyphilis. He was treated with 14 days of intravenous penicillin but had both an inflammatory reaction to the treatment and complications of tertiary syphilis. The commentary discusses the importance of conducting a complete physical examination and gathering a complete patient history, and describes the historical and cultural context of stigma that lesbian, gay, bisexual, and transgender, queer and/or questioning, intersex and asexual and/or ally (LGBTQIA) populations face.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspectives on Safety

This piece discusses Just Culture in EMS, where variation exists across systems, and challenges and opportunities to enhancing safety event reporting. 

Interview
Chris Cebollero

Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates Consulting Group. He has served as a paramedic for over 20 years, and in his last operational role he was the Chief of EMS at Christian Hospital in North St. Louis. We spoke with him about the status of safety culture in EMS and challenge associated with safety event reporting.

Interview
Jose Morfin Headshot

José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.

Perspectives on Safety

This piece discusses how the program mitigates safety risks for in-home dialysis and the potential for in-home programs to greatly expand.

Did You Know?

Upcoming & Noteworthy

Meeting/Conference
Upcoming Meeting/Conference
ISMP Medication Safety Intensive.
Institute for Safe Medication Practices. June 24-25, 2021.
Event Date
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