The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.
Providing patient-centered care continues to be a goal in both clinical settings and from a systems standpoint. While single-patient rooms have been associated with patients feeling safer, there is some debate about whether patients' satisfaction equates to their safety. This commentary advocates for single-patient rooms as a method to become more patient-centered, increase patient satisfaction, and reduce the incidence of nosocomial infections. The authors also point out important considerations with such a strategy, including costs and potential changes in workflow and related processes. However, they conclude that efforts at hospital design could have greater impact on patient safety and satisfaction than efforts at changing hospital culture.
Hayes CW, Rhee A, Detsky ME, et al. Crit Care Med. 2007;35:1668-72.
Housestaff traditionally lead cardiac arrest resuscitation ("code blue") teams at academic institutions after receiving training in Advanced Cardiac Life Support (ACLS). This survey of Canadian internal medicine residents found that most respondents felt that ACLS training alone did not leave them adequately prepared to lead resuscitations. Residents felt that their performance could be improved with greater supervision, feedback, and teamwork training to improve their leadership skills.