This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.
Patient Safety Movement Foundation. April 29-30, 2022.
Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45
Bryant A. UpToDate. September 13, 2021.
Healthcare Excellence Canada. January 27, 2022, 12:00-1:00 PM (eastern).
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.
Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.
Institute for Healthcare Improvement. March 15 - April 26, 2022.