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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

An electronic health record–based real-time analytics program for patient safety surveillance and improvement.

Classen D, Li M, Miller S, Ladner D. Health Aff (Millwood). 2018;37:1805-1812.

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.

Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study.

Pérez T, Moriarty F, Wallace E, McDowell R, Redmond P, Fahey T. BMJ. 2018;363:k4524.

Challenges and opportunities for improving patient safety through human factors and systems engineering.

Carayon P, Wooldridge A, Hose BZ, Salwei M, Benneyan J. Health Aff (Millwood). 2018;37:1862-1869.

Interpersonal and organizational dynamics are key drivers of failure to rescue.

Smith ME, Wells E, Friese CR, Krein SL, Ghaferi AA. Health Aff (Millwood). 2018;37:1870-1976.

Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs.

Geary M, Ruiter PJA, Yasseen AS III. J Interprof Care. 2018 Nov 8; [Epub ahead of print].

Newspaper/Magazine Article

Check your medical records for dangerous errors.

Graham J. Kaiser Health News. November 21, 2018.

Insulin pumps have most reported problems in FDA database.

Mohr H, Weiss M. Associated Press. November 27, 2018.

Legislation/Regulation

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper.

Nickel WK, Weinberger SE, Guze PA; Patient Partnership in Healthcare Committee of the American College of Physicians. Ann Intern Med. 2018 Nov 27; [Epub ahead of print].

Book/Report

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.

Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.

Press Release/Announcement

Test Results Follow-Up Process Survey.

Oakbrook Terrace, IL: Joint Commission.

Tools/Toolkit

ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.

Horsham, PA: Institute for Safe Medication Practices; 2018.

Latest WebM&M Issue

Expert analysis of medical errors.

Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees

  • Spotlight Case
  • CE/MOC

Olle ten Cate, PhD, November 2018

An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.

Written Signout: It Only Works If You Use The Right One

Kheyandra Lewis, MD, and Glenn Rosenbluth, MD, November 2018

Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.

Inadequate Preanesthetic Evaluation, Airway Trouble

Jeanna Blitz, MD, November 2018

When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Interview

In Conversation With… David Meltzer, MD, PhD

The Comprehensive Care Physician Model, November 2018

Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.

Perspective

The Comprehensivist Model of Care: A Hospitalist's View

The Comprehensive Care Physician Model, November 2018

Robert Wachter, MD

This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.

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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?

Common clinical effects of pediatric ADHD medication exposures reported to poison control centers.

Source

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Upcoming & Noteworthy

Taking Stepps to Sustain a Just Culture.

AHA Team Training. December 12, 2018; 1:00–2:00 PM (Eastern).

ECRI Guidelines Trust.

ECRI Institute.

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Most Viewed

Review

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

Study

Residents' response to duty-hour regulations—a follow-up national survey.

Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.

Study

Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.