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PSNet: Patient Safety Network

Issues

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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
Study
Commentary
Newspaper/Magazine Article
Book/Report

Past Issues

Weekly Resource
Study
Commentary
Newspaper/Magazine Article
Book/Report

Periodic Issue
Study
Book/Report
Newspaper/Magazine Article
Commentary

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

Periodic Issue
Study
Special or Theme Issue
Newspaper/Magazine Article
Upcoming Meeting/Conference
Commentary

WebM&M

Web M&M Edition August 2020
WebM&M Cases
Too Many Cooks in the Kitchen
Spotlight Case
CE/MOC
Richard P. Dutton, MD MBA,  

A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death. The commentary discusses the importance of multidisciplinary planning for frail patients, the contributors to, and consequences of, deviating from these plans, and the use of triggers, early warning systems, and rapid response teams to identify and respond to early signs of decompensation.

Nothing Called Small Surgery
Claire Manske, MD ,  

A 56-year-old female received a digital tourniquet around the base of her left big toe during an ablation and excision of a deformed in-grown toenail. After the procedure, a dressing was applied and the patient was discharged 4 hours later. During the follow-up visit two-days later, the dressing was removed and revealed that the tourniquet was still in place and constricting the toe. The toe became necrotic and developed gangrene, and was amputated. The commentary discusses the safe use of digital tourniquets, the importance of including tourniquets in the surgical count process, and ensuring tourniquets are removed in a timely manner.

When the Meds Don’t Reach the Bed
Mithu Molla, MD, Kathie Le, PharmD, Pamela Mendoza, PharmD ,  

A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital. The medication pick-up was delayed for several hours and there were miscommunications among the pharmacy, social worker, and physician. Ultimately, the patient was discharged without his medications and was readmitted five hours later with dyspnea and hypoxia. The commentary suggests that 7- versus 30-day readmission rates may be more reflective of hospital readmission mitigation efforts and discusses the value of Meds-to-Beds (M2B) programs in improving adherence to medication regimens during transitions of care

Perspectives

Perspectives Edition May 2020
Interview
Interview
Joel Willis, DO, PA, MA, MPhiL is a Health Policy Fellow affiliated with the American Board of Family Medicine and the George Washington Medical Faculty Associates. Neal Sikka, MD is an Associate Professor and Attending Physician at George Washington Medical Faculty Associates and the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency Medicine. We discussed with them how telehealth at GW is helping to protect patients and providers during the COVID-19 crisis.
Perspective
Perspective
Telehealth and Patient Safety During the COVID-19 Response
Telemedicine and Patient Safety
This PSNet Perspective discusses how telehealth, regardless of payer (Medicare, private insurance, etc.), is supporting both patient and provider safety during the COVID-19 crisis. Precautions that institutions can take to alleviate safety risks resulting from a rapid expansion of capabilities and use are also discussed.