Issues

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Current Issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past Issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.

Current Issue

Weekly Resource
Organizational Policy/Guidelines
Study
Review
Commentary
Book/Report
Audiovisual Presentation
Toolkit
Newspaper/Magazine Article

Past Issues

Weekly Resource
Organizational Policy/Guidelines
Study
Review
Commentary
Book/Report
Audiovisual Presentation
Toolkit
Newspaper/Magazine Article

Periodic Issue
Organizational Policy/Guidelines
Study
Commentary
Training Programs
Government Resource
Newspaper/Magazine Article
Book/Report

Periodic Issue
Government Resource
Making Healthcare Safer III.

Holmes A, Long A, Wyant B, et al. Making Healthcare Safer III. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

Study
Commentary
Book/Report
Press Release/Announcement
Newspaper/Magazine Article

Periodic Issue
Study
Review
Commentary
Web Resource
Upcoming Meeting/Conference
Press Release/Announcement
Newsletter/Journal
Newspaper/Magazine Article
Book/Report
Special or Theme Issue

WebM&M

Web M&M Edition March 2020
WebM&M Cases
Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care
Spotlight Case
CE/MOC
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.