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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.
Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework.

Etherington N, Usama A, Patey AM, Trudel C, Przybylak-Brouillard A, Presseau J, Grimshaw JM, Boet S. Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. BMJ Open Qual. Aug, 2019;8(3):e000686.;  

Government Resource
Newspaper/Magazine Article

Latest WebM&M Issue

Expert analysis of medical errors.

WebM&M Cases
The Lost Start Date: an Unknown Risk of E-prescribing
Spotlight Case
Adam Wright, PhD, and Gordon Schiff, MD,  
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily). This overdose placed him at very high risk for bleeding complications.
The Safety Challenges of Supervision and Night Coverage in Academic Residency
Katie Raffel, MD,  
An intern night float, called in on jeopardy from an outside institution for an intern who was ill, was paged to the bedside of an unstable patient to assess his condition. In the electronic health record, the intern checked the code status and clinical information, but the signout did not specify the patient’s goals of care nor what course of action to take should the patient worsen. Although the patient was listed as full code and the intern attempted to reach both the rapid response team and the senior resident, she was not aware the pager numbers were incorrect. Eventually, the intern flagged a senior resident passing in the hallway, who assessed the patient and suggested they contact his family.
Misidentifying the Unidentified – John Doe and the EHR
Christopher F. Janowak, MD, FACS, and Lauren M. Janowak, RN, BSN, CCRN,  
Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspectives on Safety
In Conversation With… Neel Shah, MD, MPP
Neonatal and Maternal Safety
Dr. Shah is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and Director of the Delivery Decisions Initiative at Harvard's Ariadne Labs. He is also the founder of the organization Costs of Care. We spoke with him about patient safety in obstetrics, maternal mortality, the importance of dignity, and the overuse of cesarean deliveries.
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Patient Safety Primers

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

Upcoming & Noteworthy

Upcoming Meeting/Conference
Ambulatory Care Conference.
Joint Commission Resources. Ambulatory Care Conference. November 14-15, 2019, Crowne Plaza Chicago O'Hare, Rosemont, IL
Upcoming Meeting/Conference
Difficult Conversations in Radiology.
Institute for Professionalism and Ethical Practice. Difficult Conversations in Radiology. November 5, 2019, Landmark Center, Boston.

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