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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
Study
Commentary
Newspaper/Magazine Article
Review
Special or Theme Issue
Tools/Toolkit
Audiovisual Presentation

Past Issues

Weekly Resource
Study
Commentary
Newspaper/Magazine Article
Review
Special or Theme Issue
Tools/Toolkit
Audiovisual Presentation

Periodic Issue
Study
Commentary
Newspaper/Magazine Article
Special or Theme Issue
Review
Book/Report

Periodic Issue
Study
Commentary
Review
Book/Report
Newsletter/Journal
Newspaper/Magazine Article

Periodic Issue
Commentary
Study
Book/Report
Press Release/Announcement
Review
Upcoming Meeting/Conference
Newspaper/Magazine Article

WebM&M

Web M&M Edition November 2020
WebM&M Cases
Premature Closure: Was It Just Syncope?
Spotlight Case
CE/MOC
David Maurier, MD and David K. Barnes, MD ,  

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died. The commentary discusses the influence of cognitive errors and the high-risk nature of anticoagulation contributing to this medical error, and the use of systematic interventions such as checklists and forcing functions to mitigate cognitive biases and prevent adverse outcomes.

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
By Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD,  

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of several perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surgery for suspected necrotizing fasciitis, but necrosis was not found. The patient returned to the surgical ICU but deteriorated; she returned to the operating room, where she was found to have necrotizing soft tissue infection, including in the flanks, labia, and uterus. She underwent extensive surgery followed by a lengthy hospital stay. The accompanying commentary discusses the contribution of knowledge deficits and cognitive biases to diagnostic errors and the importance of structured communications between professionals.

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.