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
Review
Commentary
Newspaper/Magazine Article
Press Release/Announcement
Audiovisual
Upcoming Meeting/Conference

Past Issues

Weekly Resource
Study
Review
Commentary
Newspaper/Magazine Article
Press Release/Announcement
Audiovisual
Upcoming Meeting/Conference

Periodic Issue
Study

Koers L, van Haperen M, Meijer CGF, van Wandelen SBE, Waller E, Dongelmans D, Boermeester MA, Hermanides J, Preckel B.  Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. JAMA Surg. 2019 Nov 27:e194704. doi: 10.1001/jamasurg.2019.4704. [Epub ahead of print];  

Carayon P, Hoonakker P, Hundt AS, Salwei M, Wiegmann D, Brown RL, Kleinschmidt P, Novak C, Pulia M, Wang Y, Wirkus E,  Patterson B. Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. BMJ Qual Saf. 2019 Nov 27. pii: bmjqs-2019-009857. doi: 10.1136/bmjqs-2019-009857. [Epub ahead of print];  

Commentary

Yorio PL, Edwards J, Hoeneveld D. Safety culture across cultures. Saf Sci. 2019 Dec;120:402-410. doi: 10.1016/j.ssci.2019.07.021.;  

Khorana MM, Khorana AA. Measuring quality. JAMA. 2019 Dec 3;322(21):2077-2078. doi: 10.1001/jama.2019.18730.;  

Grant Announcement
Book/Report
Multi-use Website

New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem Association of Pennsylvania. Q3 Health Innovation Partners.;  

Upcoming Meeting/Conference
Georgia Meeting/Conference
Special or Theme Issue

Halamek LP, ed. Patient Safety. Semin Perinatol. 2019;43(8):151172-151182.;  

Periodic Issue
Study

Donnelly EA, Bradford P, Davis M, Hedges C, Socha D, Morassutti P. Fatigue and Safety in Paramedicine. Cjem. Nov, 2019;21(6):762-765.;  

Newspaper/Magazine Article
Review
Book/Report
Commentary
Meeting/Conference

American College of Healthcare Executives. Congress on Healthcare Leadership, Hyatt Regency—Chicago, Chicago, IL, March 23–26, 2020.;  

Periodic Issue
Study
Review
Commentary
Audiovisual
Book/Report
Newspaper/Magazine Article
Tools/Toolkit
Upcoming Meeting/Conference

WebM&M

Web M&M Edition December 2019
WebM&M Cases
"Do You Want Everything Done?": Clarifying Code Status
Spotlight Case
CE/MOC
Karl Steinberg, MD, CMD, HMDC and Thaddeus Mason Pope, JD, PhD ,  
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
The Need to Eat
Adrianne M Widaman, PhD, RD ,  
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
A Mistaken Dose of Naloxone 
Erika Cutler, PharmD, and Delani Gunawardena, MD ,  
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.