PSNet Weekly Update 9/18/2019
What's new in patient safety literature, news, & more.
Romero-Brufau S, Gaines K, Nicolas CT, Johnson MG, Hickman J, Huddleston JM. JAMIA Open. 2019 Aug 28; [Epub ahead of print].
Koyama AK, Maddox CS, Li L, Bucknall T, Westbrook JI. BMJ Qual Saf. 2019 Aug 7; [Epub ahead of print].
Pinkney SJ, Fan M, Koczmara C, Trbovich PL. Crit Care Med. 2019;47:e597-e601.
Ellis RJ, Schlick CJR, Feinglass J, et al. BMJ Qual Saf. 2019 Jul 31; [Epub ahead of print].
Farre A, Heath G, Shaw K, Bem D, Cummins C. BMJ Qual Saf. 2019 Jul 29; [Epub ahead of print].
Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059.
Hagley G, Mills PD, Watts BV, Wu AW. BMJ Open Qual. 2019;8:e000646.
Special or Theme Issue
Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.
O'Rourke M. The Atlantic. September 2019.
Palmer J. Patient Saf Qual Healthc. August 29, 2019.
American College of Healthcare Executives. October 10–11, 2019; Cleveland Clinic, Cleveland, OH.
Latest WebM&M Issue
Expert analysis of medical errors.
- Spotlight Case
Hildy Schell-Chaple, RN, PhD, September 2019
After undergoing a scheduled percutaneous coronary intervention, a man with a femoral sheath still in place was admitted to the medical ward, where several beds had recently been converted to cardiac telemetry beds. Having limited experience with femoral sheaths, the nurse removed it but was unable to assess the patient every 15 minutes as required due to becoming busy with another patient. One hour later, the patient was unresponsive, a code was called, and he was transferred to the intensive care unit where he died several hours later.
Andrew P. Olson, MD, September 2019
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed.
Zara Cooper, MD, MSc, September 2019
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.
Expert viewpoints on current themes in patient safety.
Patient Safety at 20, September 2019
Dr. Agrawal is president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.
Patient Safety at 20, September 2019
Sumant Ranji, MD, and Robert M. Wachter, MD
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
Patient Safety Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.
Upcoming & Noteworthy
American College of Healthcare Executives and Society to Improve Diagnosis in Medicine. September 24, 2019, 12:00–1:30 PM (Eastern).
Patient Safety Learning. October 2, 2019; London, UK.
Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.
Upadhyay S, Weech-Maldonado R, Lemak CH, Stephenson A, Mehta T, Smith DG. Health Care Manage Rev. 2018 Aug 28; [Epub ahead of print].
Ryan J. KUOW. National Public Radio. August 1, 2013.