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PSNet: Patient Safety Network

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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 12/2/2020

What's new in patient safety literature, news, & more.
Study
Review
Audiovisual Presentation

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
Premature Closure: Was It Just Syncope?
Spotlight Case
CE/MOC
David Maurier, MD and David K. Barnes, MD ,  

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died. The commentary discusses the influence of cognitive errors and the high-risk nature of anticoagulation contributing to this medical error, and the use of systematic interventions such as checklists and forcing functions to mitigate cognitive biases and prevent adverse outcomes.

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
By Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD,  

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surgery for suspected necrotizing fasciitis, but necrosis was not found. The patient returned to the surgical ICU but deteriorated; she returned to the operating room, where she was found to have necrotizing soft tissue infection, including in the flanks, labia, and uterus. She underwent extensive surgery followed by a lengthy hospital stay. The accompanying commentary discusses the contribution of knowledge deficits and cognitive biases to diagnostic errors and the importance of structured communications between professionals.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspective

This piece discusses the challenges faced by long-term care facilities in responding to the COVID-19 pandemic, with a particular focus on visitor restrictions, staffing turnover, and infection prevention and control. 

Interview
Lori Popejoy

Charles A Crecelius, MD, PhD CMD, is the Medical Director for post-acute care at BJC Medical Group and the Project Medical Director for the Missouri Quality Initiative (MOQI). Lori L Popejoy, PhD, RN, FAAN is an Associate Dean for Innovation and Partnerships and an Associate Professor at the University of Missouri Sinclair School of Nursing. We discussed with them the response to the COVID-19 pandemic in long-term care facilities.

Perspective

This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.

Interview
George Edwin

Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.

Did You Know?

Upcoming & Noteworthy

Meeting/Conference
Maryland Meeting/Conference
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. December 7-11, 2020; Armstrong Institute for Patient Safety and Quality, Baltimore, MD.
Event Date
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