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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 4/1/2020

What's new in patient safety literature, news, & more.
Organizational Policy/Guidelines

Latest WebM&M Issue

Expert analysis of medical errors.
WebM&M Cases
Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care
Spotlight Case
David Barnes, MD, FACEP and Rita Chang, MD,  
A 46-year-old woman presented to the emergency department (ED) triage with a history of a stroke, methamphetamine use, and remote endovascular repair of a thoracic aortic dissection. Her chief complaint was abdominal pain and vomiting and she was assigned Emergency Severity Index (ESI) category 2; however, there were no available beds, so the patient remained in the waiting room. Several hours later, she began to scream in pain on the waiting room floor, was quickly assessed as needing surgery; however, surgery was delayed, and the patient died in the ED.
Right Electrocardiogram, Wrong Patient
Christopher Chen, MD and Sandhya Venugopal, MD, MS-HPEd,  
The patient safety committee at a large tertiary care hospital received nine incident reports within three months involving electrocardiogram (EKG) reports that were uploaded into the wrong patients’ chart. All of these events were due to users failing to clear the previous patient’s information from, and/or users failing to enter the new patient’s information into, the EKG machine when obtaining an EKG.
Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
Christian Bohringer, MD,  
Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.

Latest Perspective

Expert viewpoints on current themes in patient safety.
This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
Annual Perspective
Patient Safety in Medical, Nursing, and Other Clinical Education
Medical Education and Patient Safety
This piece describes key themes reflected in AHRQ PSNet resources released in 2019 related to how medical, nursing, and other clinical education can better incorporate patient safety concepts.
Annual Perspective
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to the role of the pharmacist in enhancing patient safety.
Annual Perspective
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.
View more information.

Patient Safety Primers

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

Did You Know?

Upcoming & Noteworthy

Georgia Meeting/Conference
Patient Safety Certificate Program.
American Society for Healthcare Risk Management. April 20-23, 2020, Whitley Atlanta Buckhead, Atlanta, GA.

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