Zagury-Orly I, Schwartzstein RM. N Engl J Med. 2020;383:e12.
This article discusses the challenges of clinical decision-making and the influence of cognitive biases during the COVID-19 pandemic. The authors discuss the importance of using evidence-based care in treating patients and reserving anecdotal observations for hypothesis generation.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.
Wiener RS, Schwartz LM, Woloshin S. Arch Intern Med. 2011;171:831-7.
Since the introduction of new diagnostic technologies in the late 1990s, pulmonary embolism diagnoses have increased, but mortality from pulmonary embolisms has not decreased. This combination of findings likely represents overdiagnosis—either due to false-positive diagnoses or detection (and treatment) of clinically insignificant clots.
Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-25.
Accurate initial assessment and resuscitation of trauma patients is critical to ensuring correct treatment and survival, and although standardized algorithms have been developed for initial trauma evaluation, errors are not uncommon. This innovative randomized controlled trial implemented a computerized clinician decision support system (CDSS) to ensure adherence to standardized protocols for trauma resuscitation, and used video capture of trauma resuscitations to assess the effects of the CDSS on patient outcomes. Use of the CDSS resulted in significantly reduced errors, and also reduced morbidity compared to standard treatment. This study demonstrates the utility of a CDSS in a fast-paced, high-acuity environment.
Smits M, Huibers L, Kerssemeijer B, et al. BMC Health Serv Res. 2010;10:335.
This study found a low rate of patient safety incidents involving telephone care interactions. Most incidents were related to failures in clinical reasoning. A past AHRQ WebM&M commentary discussed potential pitfalls in providing medical advice by telephone.
A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade.
This study analyzed communication errors during call bookings for air medical transport and found both human and process-driven root causes. Examples of major errors identified were commissions of allergies to medications and omissions of intubations from records.
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.
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