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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.
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
Patricia McGaffigan is the Vice President for Safety Programs at the Institute for Healthcare Improvement and President of the Certification Board for Professionals in Patient Safety. We spoke to Patricia about patient safety trends and how patient safety will move beyond the pandemic.
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.
Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.
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.
This piece focuses on human factors engineering including application of the SEIPS model to implement care transitions rooted in patient safety and the processes of care.
This piece focuses on human factors engineering including application of the SEIPS model to implement care transitions rooted in patient safety and the processes of care.
Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.
A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved.
AMA J Ethics. 2022;24(8):e715-e816.
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.
