PSNet Weekly Update 7/18/2018
What's new in patient safety literature, news, & more.
Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018 Jul 9; [Epub ahead of print].
Centers for Medicare and Medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.
Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018 Jun 28; [Epub ahead of print].
Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. JAMA Network Open. 2018;1:e180217.
Alingh CW, van Wijngaarden JDH, van de Voorde K, Paauwe J, Huijsman R. BMJ Qual Saf. 2018 Jun 28; [Epub ahead of print].
Davis DP, Aguilar SA, Lawrence B, Minokadeh A, Sell SE, Husa RD. Jt Comm J Qual Patient Saf. 2018;44:413-420.
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
Boston, MA: Institute for Healthcare Improvement; 2018.
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
Jt Comm J Qual Patient Saf. 2018;44:373-400.
Harvard Medical School. Boston, MA.
Agency for Healthcare Research and Quality. July 25, 2018; 2:00–2:50 PM (Eastern).
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Resa E. Lewiss, MD, July 2018
After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.
Rita L. McGill, MD, MS, July 2018
Admitted to the hospital with an ulcer on his right foot, a man with diabetes and stage IV chronic kidney disease had an MRI concerning for osteomyelitis, and a bone biopsy showed chronic inflammation with cultures positive for methicillin-sensitive Staphylococcus aureus. To administer outpatient parenteral antimicrobial therapy, interventional radiology attempted to place a peripherally inserted central catheter (PICC) in the right brachial vein multiple times but failed. They then placed it in the left brachial vein. The patient completed 6 weeks of antibiotic therapy and wound care, and the PICC was removed. Five months later with worsening renal function and hyperphosphatemia, the patient required dialysis access, but he was not a candidate for arteriovenous fistula placement since the many venipuncture attempts during PICC placement resulted in poor vein quality.
Deborah Debono, PhD, RN, and Tracy Levett-Jones, PhD, RN, July 2018
A young adult with a progressive neurological disorder presented to an emergency department from a nursing home with a dislodged GJ tube. As a workaround to maintain patency when the GJ tube was dislodged, nursing home staff had inserted a Foley catheter into the ostomy, inflated the Foley bulb in the stomach, and tied the distal portion of the catheter in a loose knot. When the patient went to interventional radiology for new GJ tube placement, clinicians found no Foley but inserted a new GJ tube. Discharged to the nursing home, the patient was readmitted 2 days later with fever and increasing abdominal distention. An abdominal CT scan showed an obstructing foreign body in the small bowel.
Expert viewpoints on current themes in patient safety.
Improving Diagnosis, July 2018
Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School, and Quality and Safety Director for the Harvard Medical School Center for Primary Care. He was an invited expert and reviewer for the Improving Diagnosis in Health Care report of the National Academy of Medicine. We spoke with him about understanding and preventing diagnostic errors.
Improving Diagnosis, July 2018
Dr. Nundy is the Director of the Human Diagnosis Project, a nonprofit organization taking a unique crowdsourcing approach to improving medical diagnosis. He also practices primary care at a federally qualified health center for low-income and uninsured individuals in Washington, DC. We spoke with him about his work with the Human Diagnosis Project.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Society to Improve Diagnosis in Medicine and Patient Safety Switzerland. August 30–31, 2018, Inselspital University Hospital, Bern, Switzerland.
Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, University of Chicago.
O'Reilly KB. American Medical News. August 15, 2011.
Butler K, Mollo P, Gale JL, Rapp DA. Jt Comm J Qual Patient Saf. 2007;33:527-536.
Elnour AA, Ellahham NH, Al Qassas HI. Pharm World Sci. 2008;30:182-190.