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Cases & Commentaries
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Rita Redberg, MD, MSc; December 2011
A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.
Journal Article > Study
Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.
The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.
McCook A. Anesthesiology News. Sept 2011;37:9.
This news article highlights a program at Johns Hopkins Medicine that engages clinician reporting of errors and near misses to improve patient safety.