PSNet Weekly Update 12/6/2017
What's new in patient safety literature, news, & more.
Schwartz ME, Welsh DE, Paull DE, et al. J Healthc Risk Manag. 2017 Nov 9; [Epub ahead of print].
Cox ED, Hansen K, Rajamanickam VP, et al. Hosp Pediatr. 2017 Nov 15; [Epub ahead of print].
Boockvar KS, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.
Classen DC, Griffin FA, Berwick DM. Ann Intern Med. 2017 Nov 21; [Epub ahead of print].
Eccleston C, Fisher E, Thomas KH, et al. Cochrane Database Syst Rev. 2017;11:CD010323.
Sarkar U, McDonald K, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.
Santana MJ, Holroyd-Leduc J, Southern DA, et al; e-DCT Team. BMJ Qual Saf. 2017;26:993-1003.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Special or Theme Issue
AJR Am J Roentgenol. 2017;209:965-1008;W333-W334.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA, December 2017
Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.
Ian Solsky, MD, and Alex B. Haynes, MD, MPH, December 2017
Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding.
Varalakshmi Janamanchi, MD; Kunjam Modha, MD; and Christopher Whinney, MD, December 2017
At a preoperative evaluation for skin grafting surgery, a man's prescription medications were reviewed and updated in his medical record. During surgery, the patient experienced profuse bleeding, requiring transfusion with multiple units of blood. Postoperatively, the patient stabilized and the attending surgeon reexamined the patient's medications with him and asked about over-the-counter medications. The patient had been taking one aspirin per day, including the day of surgery. Although the patient was asked about blood-thinning medications at the preoperative visit, he was not asked about over-the-counter medications.
Expert viewpoints on current themes in patient safety.
Surgical Safety, December 2017
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Surgical Safety, December 2017
Robert M. Wachter, MD
This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Institute for Healthcare Improvement. December 10–13, 2017; World Center Marriott, Orlando, FL.
Indianapolis, IN: Anesthesia Patient Safety Foundation.
Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.
Berwick DM. N Engl J Med. 1989;320:53-56.
Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.