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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.

PSNet Weekly Update 7/8/2020

What's new in patient safety literature, news, & more.
The Care We Need

The Care We Need. Washington DC: National Quality Forum; 2020.

Caring for Caregivers.

Institute for Health Care Improvement, Wellbeing Trust. Caring for Caregivers. July 10-September 11, 2020. 10:00-11:00 am (Eastern).

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
When the Indications for Drug Administration Blur
Spotlight Case
Julia Munsch, PharmD and Amy Doroy, PhD, RN ,  
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
Janeane Giannini, PharmD, Melinda Wong, PharmD, William Dager, PharmD, Scott MacDonald, MD, and Richard H. White, MD ,  
A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion. The commentary discusses the challenges associated with prescribing direct-action oral anticoagulants (DOACs) and how computerized clinical decision support tools can promote adherence to guideline recommendations and mitigate the risk of error, and how tools such as standardized teaching materials and teach-back can support patient understanding of medication-related instructions.
Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
Malcom Mackenzie, MD and Celeste Royce, MD,  
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this case, a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure to validate a young woman’s complaints resulted in a 12-year diagnostic delay and significant physical and psychologic morbidity.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Anna Dopp
In Conversation With... Anna Legreid Dopp
Pharmacy and Safety
Anna Legreid Dopp is the Senior Director of Clinical Guidelines and Quality Improvement at the American Society of Health-System Pharmacists (ASHP). We spoke with her about how pharmacist care delivery services have been impacted by COVID-19.
Jeffrey Shuren
Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food and Drug Administration. We spoke with him about the role of the Food and Drug Administration in ensuring the safety of medical devices.

Did You Know?

Upcoming & Noteworthy

Audiovisual Presentation
Finding & Creating Joy in Work.
Institute for Healthcare Improvement. September 8--November 24, 2020.
Event Date
Arizona Meeting/Conference
Patient Safety Certificate Program.
American Society for Healthcare Risk Management. October 11-14, 2020, The Phoenix Convention Center, Phoenix, AZ.
Event Date