COVID-19 Impact

You may see some delays in posting new content due to COVID-19. If you have any questions, please submit a message to PSNet Support.
 

PSNet: Patient Safety Network

Welcome to PSNet

PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more.

PSNet Weekly Update 11/25/2020

What's new in patient safety literature, news, & more.
Study
Commentary
Newspaper/Magazine Article
Review
Special or Theme Issue

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Spotlight Case
CE/MOC
Berit Bagley, MSN, Dahlia Zuidema, PharmD, Stephanie Crossen, MD, and Lindsey Loomba, MD ,  

A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct. Further evaluation led to a diagnosis of antiphospholipid syndrome. The patient was persistently hyperglycemic despite glycemic management using her home insulin pump and continuous glucose monitor. Over the course of her hospitalization, her upper extremity symptoms worsened, and she developed upper extremity, chest, and facial paresthesia. Imaging studies revealed new right MCA territory infarcts as well as splenic and bilateral infarcts. The case describes how suboptimal inpatient management of diabetes technology contributed to persistent hyperglycemia in the setting of an acute infarction. The commentary discusses best practices for optimizing patient safety when managing hospitalized patients on home insulin pumps. 

When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Kathy Ton, PharmD ,  

A 58-year-old female receiving treatment for transformed lymphoma was admitted to the intensive care unit (ICU) with E. coli bacteremia and colitis secondary to neutropenia, and ongoing hiccups lasting more than 48 hours. She was prescribed thioridazine 10 mg twice daily for the hiccups and received four doses without resolution; the dose was then increased to 15 mg and again to 25 mg without resolution. When she was transferred back to the inpatient floor, the pharmacist, in reviewing her records and speaking with the resident physician, thioridazine (brand name Mellaril) had been prescribed when chlorpromazine (brand name Thorazine) had been intended. The commentary discusses the use of computerized physician order entry (CPOE) to reduce prescribing errors in inpatient settings and the importance of having a pharmacist on the patient care team to avoid prescribing errors involving less commonly prescribed medications. 

Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.
Christi DeLemos, MSN, CNRN, ACNP-BC ,  

A 73-year-old female underwent a craniotomy and aneurysm clipping to resolve a subarachnoid hemorrhage due to a ruptured aneurysm. The neurosurgery resident confirmed the presence of neuromonitoring with the Operating Room (OR) front desk but the neuromonitoring technician never arrived and the surgeon – who arrived after the pre-op huddle – decided to proceed with the procedure in their absence. Although no problems were identified during surgery, the patient emerged from anesthesia with left-sided paralysis, and post-op imaging showed evidence of a new stroke. The commentary discusses the importance of huddles, ensuring closed-loop communication involving residents, and balancing benefits and risks during emergent surgical care.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspective

This piece discusses the challenges faced by long-term care facilities in responding to the COVID-19 pandemic, with a particular focus on visitor restrictions, staffing turnover, and infection prevention and control. 

Interview
Lori Popejoy

Charles A Crecelius, MD, PhD CMD, is the Medical Director for post-acute care at BJC Medical Group and the Project Medical Director for the Missouri Quality Initiative (MOQI). Lori L Popejoy, PhD, RN, FAAN is an Associate Dean for Innovation and Partnerships and an Associate Professor at the University of Missouri Sinclair School of Nursing. We discussed with them the response to the COVID-19 pandemic in long-term care facilities.

Perspective

This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.

Interview
George Edwin

Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.

Did You Know?

Upcoming & Noteworthy

Meeting/Conference
Upcoming Meeting/Conference
ISMP Medication Safety Intensive.
Institute for Safe Medication Practices. December 4-5, 2020
Event Date
-

Most Viewed