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Cases & Commentaries
- Spotlight Case
- Web M&M
Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
Journal Article > Study
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.