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A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.
A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents.
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.
In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.
Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.
Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.
We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.
A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.
A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits.
This piece focuses on measuring and monitoring patient safety in the prehospital setting.
This piece focuses on measuring and monitoring patient safety in the prehospital setting.
Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.
