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Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38:1281-1288.
Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.
First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused.
At a skilled nursing facility, an elderly woman with myelodysplastic syndrome was found to be mildly anemic, and her oncologist arranged for her to be sent to the hospital and transfused with 2 units of blood. Less than 1 hour after the second unit of blood finished transfusing, the patient rapidly worsened and had a respiratory arrest.

Baker GR, ed. Healthc Q. 2009;12(Spec No Patient):1-198.  

This special issue discusses Canadian patient safety efforts in identifying risks, designing safe systems, implementing solutions, developing learning systems, and understanding legal decision making.
Golden, CO: HealthGrades, Inc.; April 2009. 
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.
Anderson HJ. Health Data Manag. 2009;17:18-20, 22, 24 passim.
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors, a mere 8% of hospitals use the system and fewer implement it effectively, according to the Leapfrog Group CPOE evaluation tool.
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.