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PSNet: Patient Safety Network

Issues

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PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Current Issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past Issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.

Current Issue

Weekly Resource
Commentary
Review
Study
Newspaper/Magazine Article
Multi-use Website
Grant Announcement

Past Issues

Weekly Resource
Commentary
Review
Study
Newspaper/Magazine Article
Multi-use Website
Grant Announcement

Periodic Issue
Fact Sheet/FAQs
Commentary
Study
Review
Newspaper/Magazine Article
Book/Report
Press Release/Announcement

Periodic Issue
Review
Study
Newspaper/Magazine Article
Audiovisual Presentation
Press Release/Announcement
Sentinel Event Alerts
Book/Report

Periodic Issue
Study
Review
Upcoming Meeting/Conference
Press Release/Announcement
Toolkit
Measurement Tool/Indicator
Book/Report

WebM&M

Web M&M Edition February 2021
WebM&M Cases
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Spotlight Case
CE/MOC
David Barnes, MD and William Ken McCallum, MD,  

A 56-year-old women with a history of persistent asthma presented to the emergency department (ED) with shortness of breath and chest tightness that was relieved with Albuterol. She was admitted to the hospital for acute asthma exacerbation. Given a recent history of mobility limitations and continued clinical decompensation, a computed tomography (CT) angiogram of the chest was obtained to rule out pulmonary embolism (PE).  The radiologist summarized his initial impression by telephone to the primary team but the critical finding (“profound evidence of right heart strain") was not conveyed to the primary team. The written radiology impression was not reviewed, nor did the care team independently review the CT images. The team considered her to be low-risk and initiated therapy with a direct oral anticoagulant (DOAC). Later that day, the patient became hemodynamically unstable and was transferred to the intensive care unit (ICU). She developed signs of stroke and required ongoing resuscitation overnight before being transitioned to comfort care and died. This commentary discusses the importance of avoiding anchoring bias, effective communication between care team members, and reviewing all available test results to avoid diagnostic errors.

Perspectives

Perspectives Edition May 2020
Interview
Interview
Joel Willis, DO, PA, MA, MPhiL is a Health Policy Fellow affiliated with the American Board of Family Medicine and the George Washington Medical Faculty Associates. Neal Sikka, MD is an Associate Professor and Attending Physician at George Washington Medical Faculty Associates and the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency Medicine. We discussed with them how telehealth at GW is helping to protect patients and providers during the COVID-19 crisis.
Perspective
Perspective
Telehealth and Patient Safety During the COVID-19 Response
Telemedicine and Patient Safety
This PSNet Perspective discusses how telehealth, regardless of payer (Medicare, private insurance, etc.), is supporting both patient and provider safety during the COVID-19 crisis. Precautions that institutions can take to alleviate safety risks resulting from a rapid expansion of capabilities and use are also discussed.