PSNet Weekly Update 11/14/2018
What's new in patient safety literature, news, & more.
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Djukic M, Stimpfel AW, Kovner C. Jt Comm J Qual Patient Saf. 2018 Oct 15; [Epub ahead of print].
Mann S, Hollier LM, McKay K, Brown H. N Engl J Med. 2018;379:1689-1691.
Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2018 Oct 18; [Epub ahead of print].
Gopalan A, Mishra P, Alexeeff SE, et al. Diabet Med. 2018 Sep 3; [Epub ahead of print].
Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.
Myers JS, Bellini LM. Acad Med. 2018;93:1321-1325.
Gawande A. New Yorker. November 12, 2018.
DeMarco P. Globe Magazine. November 3, 2018.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Itasca, IL: American Academy of Pediatrics; 2018.
Patient Safety Learning: London, UK; September 2018.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
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.
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.
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.
Expert viewpoints on current themes in patient safety.
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.
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.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
Armstrong Institute for Patient Safety and Quality. November 27–29, 2018; Johns Hopkins Hospital, Baltimore, MD.
Institute for Healthcare Improvement. November 27, 2018–January 22, 2019.
Welp A, Meier LL, Manser T. Crit Care. 2016;20:110.
Wubben I, van Manen JG, van den Akker BJ, Vaartjes SR, van Harten WH. Qual Saf Health Care. 2010;19:e64.
ISMP Medication Safety Alert! Acute Care Edition. January 28, 2016;21:1-4. February 11, 2016;21:1-5.