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PSNet: Patient Safety Network

Welcome to PSNet

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

PSNet Weekly Update 3/3/2021

What's new in patient safety literature, news, & more.
Study
Commentary
Newspaper/Magazine Article

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Spotlight Case
CE/MOC
David Barnes, MD and William Ken McCallum, MD,  

A 56-year-old women with a history of persistent asthma presented to the emergency department (ED) with shortness of breath and chest tightness that was relieved with Albuterol. She was admitted to the hospital for acute asthma exacerbation. Given a recent history of mobility limitations and continued clinical decompensation, a computed tomography (CT) angiogram of the chest was obtained to rule out pulmonary embolism (PE).  The radiologist summarized his initial impression by telephone to the primary team but the critical finding (“profound evidence of right heart strain") was not conveyed to the primary team. The written radiology impression was not reviewed, nor did the care team independently review the CT images. The team considered her to be low-risk and initiated therapy with a direct oral anticoagulant (DOAC). Later that day, the patient became hemodynamically unstable and was transferred to the intensive care unit (ICU). She developed signs of stroke and required ongoing resuscitation overnight before being transitioned to comfort care and died. This commentary discusses the importance of avoiding anchoring bias, effective communication between care team members, and reviewing all available test results to avoid diagnostic errors.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspective

This piece discusses prevalent adverse events in dental care and the challenges in identifying these patient safety events.

Interview
Muhammad Walji

Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.   

Interview
Katie Suda

Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medicine in the Division of General Internal Medicine. She is a pharmacist by training with a specialty in infectious diseases and a research concentration in the area of dental antibiotic and opioid stewardship. We discussed antibiotic and opioid prescribing in dental care and challenges for implementing stewardship programs.

Did You Know?

Upcoming & Noteworthy

Meeting/Conference
Upcoming Meeting/Conference
Redesigning Event Review with RCA2

Institute for Healthcare Improvement. March 16 - May 18, 2021.

Event Date
-

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