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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

What's new in patient safety literature, news, & more.
Special or Theme Issue
Newspaper/Magazine Article
Fact Sheet/FAQs
Government Resource

Latest WebM&M Issue

Expert analysis of medical errors.

WebM&M Cases
Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation
Caitlin E. Kulig, PharmD and Imo A. Ebong, MBBS, MS,  
A young woman is admitted with abdominal pain, nausea, and weakness and found to have a urinary tract infection and was started on intravenous levofloxacin. She also received her home medications, which included lithium and an atypical antipsychotic (quetiapine) along with lithium for bipolar disease and multiple doses of intravenous ondansetron and metoclopramide as treatment for nausea. Subsequently, she was observed to be bradycardic with a widening QRS complex on telemetry and became pulseless and unresponsive. Luckily, advanced cardiac life support was implemented with a return of heartbeat and circulation. The use of common medications that caused QT prolongation contributed to this adverse event.
Missed Opportunities for Suicide Risk Assessment
Spotlight Case
Glen Xiong, MD and Debra Kahn, MD,  
Two different patients were seen in the emergency department a history of excessive alcohol consumption and suicidal ideation along with other medical comorbidities. In both cases, acute medical conditions prevented a comprehensive psychiatric evaluation being completed by psychiatric emergency services. Unfortunately, both patients were discharged after resolution of their medical conditions and were later found dead.
Complications of Vascular Access Procedures in Patients with Kidney Disease
Sierra Rayne Young, Pharm.D. and Iris Chen, Pharm.D., BCPS, BCOP,  
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspectives on Safety
Heidi Wald
Patient Safety in Frail Older Patients: Interview with Dr. Heidi Wald
Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as a physician advisor for the Colorado Hospital Association and as a Quality Committee Chair for the American Geriatrics Society. We spoke with her about patient safety concerns when caring for frail older patients.
Perspectives on Safety
Patient Safety in Frail Older Patients
This piece describes patient safety risks when caring for frail older patients and summarizes potential approaches for clinicians to minimize this risk.
View more information.

Patient Safety Primers

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

Upcoming & Noteworthy

Audiovisual Presentation
Deep dive into error disclosure.
Boston Children's Hospital; Institute for Professionalism and Ethical Practice. Deep dive into error disclosure. December 10, 2019, 12:00-2:00 pm (Eastern).
Upcoming Meeting/Conference
TeamSTEPPS Next Steps Workshop.
AHA Team Training. TeamSTEPPS Next Steps Workshop. March 4–5, 2020; University of Washington, Seattle, WA.

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