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PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more.

Journal Article

A decade of preventing harm.

Woeltje KF, Olenski LK, Donatelli M, et al. Jt Comm J Qual Patient Saf. 2019 May 24; [Epub ahead of print].

Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review.

Klimas J, Gorfinkel L, Fairbairn N, et al. JAMA Netw Open. 2019;2:e193365.

The impacts of medication shortages on patient outcomes: a scoping review.

Phuong JM, Penm J, Chaar B, Oldfield LD, Moles R. PLoS One. 2019;14:e0215837.

New persistent opioid use after postoperative intensive care in US veterans.

Karamchandani K, Pyati S, Bryan W, et al. JAMA Surg. 2019 Jun 5; [Epub ahead of print].

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.

Li RC, Wang JK, Sharp C, Chen JH. BMJ Qual Saf. 2019 Jun 4; [Epub ahead of print].

Book/Report

Meeting/Conference

Disclosure and Apology in Radiology.

Institute for Professionalism and Ethical Practice. June 26, 2019, 9:00–11:00 AM (Eastern).

Special or Theme Issue

Legislation/Regulation

Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians.

Candilis PJ, Kim DT, Sulmasy LS; ACP Ethics, Professionalism and Human Rights Committee. Ann Intern Med. 2019 Jun 4; [Epub ahead of print].

Newspaper/Magazine Article

A mismatch made in America.

Butcher L. Managed Care. June 2019;28:37-39.

Latest WebM&M Issue

Expert analysis of medical errors.

Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout

  • Spotlight Case
  • CE/MOC

Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD, June 2019

A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.

Delayed Sepsis Management Due to Ambiguous Allergy

Kimberly G. Blumenthal, MD, MSc, June 2019

Transferred to the emergency department from the transfusion center after becoming unresponsive and hypotensive, an elderly man with signs of sepsis is given incomplete and delayed antimicrobial coverage due to a history of penicillin allergy. Neither gram-negative nor anaerobic coverage were provided until several hours later, and the patient developed septic shock.

If You Say So: Taking a Syringe at Face Value in the Operating Room

Audrey Lyndon, PhD, RN, and Stephanie Lim, MD, June 2019

During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Interview

In Conversation With… Erik Hollnagel, PhD

Resilience Engineering and Patient Safety, June 2019

Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting Professorial Fellow at Macquarie University in Sydney (Australia). We spoke with him about his work studying safety in health care and the differences between designing safety improvements in health care versus other industries.

Perspective

Building a Safety Program Using Principles of Resilience Engineering

Resilience Engineering and Patient Safety, June 2019

Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS

This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.

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Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

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Did You Know?

Change in application of safety science principles pre- and post-implementation of AHRQ Safety Program for Perinatal Care.

Source

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Upcoming & Noteworthy

TeamSTEPPS Master Training Course.

Johns Hopkins Armstrong Institute for Patient Safety and Quality. June 25–26, 2019; Constellation Energy Building, Baltimore, MD.

CPS Annual Reports.

Jefferson City, MO: Center for Patient Safety; June 11, 2019.

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Most Viewed

Commentary

Continuous improvement as an ideal in health care.

Berwick DM. N Engl J Med. 1989;320:53-56.

Book/Report

Prevalence and Economic Burden of Medication Errors in the NHS England.

Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.

Commentary

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.