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
Study
Book/Report
The Care We Need

The Care We Need. Washington DC: National Quality Forum; 2020.

Meeting/Conference
Caring for Caregivers.

Institute for Healthcare Improvement, Wellbeing Trust. Caring for Caregivers. July 10-September 11, 2020. 10:00-11:00 am (Eastern).

Special or Theme Issue
Newspaper/Magazine Article

Past Issues

Weekly Resource
Commentary
Study
Book/Report
The Care We Need

The Care We Need. Washington DC: National Quality Forum; 2020.

Meeting/Conference
Caring for Caregivers.

Institute for Healthcare Improvement, Wellbeing Trust. Caring for Caregivers. July 10-September 11, 2020. 10:00-11:00 am (Eastern).

Special or Theme Issue
Newspaper/Magazine Article

Periodic Issue
Study
Commentary
Review
Book/Report

Periodic Issue
Commentary
Study
Newspaper/Magazine Article
Upcoming Meeting/Conference
Special or Theme Issue

Periodic Issue
Study
Commentary
Toolkit
Audiovisual Presentation

WebM&M

Web M&M Edition June 2020
WebM&M Cases
When the Indications for Drug Administration Blur
Spotlight Case
CE/MOC
Julia Munsch, PharmD and Amy Doroy, PhD, RN ,  
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
Janeane Giannini, PharmD, Melinda Wong, PharmD, William Dager, PharmD, Scott MacDonald, MD, and Richard H. White, MD ,  
A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion. The commentary discusses the challenges associated with prescribing direct-action oral anticoagulants (DOACs) and how computerized clinical decision support tools can promote adherence to guideline recommendations and mitigate the risk of error, and how tools such as standardized teaching materials and teach-back can support patient understanding of medication-related instructions.
Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
Malcom Mackenzie, MD and Celeste Royce, MD,  
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this case, a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure to validate a young woman’s complaints resulted in a 12-year diagnostic delay and significant physical and psychologic morbidity.

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.