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Cases & Commentaries
- Web M&M
B. Joseph Guglielmo, PharmD; March 2007
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Journal Article > Study
Avansino J, Leu MG. Pediatrics. 2012;130:e547-e552.
Journal Article > Study
Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers.
Coughlin JM, Shallcross ML, Schäfer WLA, et al. J Surg Res. 2019;239:309-319.
Prior studies have found that patients are often prescribed opioids inappropriately after undergoing surgery. This qualitative study reports on the implementation of a multifaceted effort to reduce opioid prescribing and standardize postoperative pain management at an academic hospital. The investigators identified several barriers to improving prescribing, including time and resource constraints and fear of harming patient satisfaction.
Journal Article > Review
Neuman MD, Bateman BT, Wunsch H. Lancet. 2019;393:1547-1557.
The overprescribing of opioids for postsurgery pain can increase the potential for opioid dependence, misuse, and harm. Discussing this worldwide patient safety concern, this commentary summarizes clinician, patient, and systemic factors that contribute to the problem and outlines efforts to address the issue while enabling clinicians to provide safe pain therapy to patients.