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
Special or Theme Issue
Newspaper/Magazine Article
Fact Sheet/FAQs
Government Resource
Image/Poster
Study
Review
Commentary

Past Issues

Issue Date

Weekly Resource
Special or Theme Issue
Newspaper/Magazine Article
Fact Sheet/FAQs
Government Resource
Image/Poster
Study
Review
Commentary

Periodic Issue
Study

Dharmarajan TS, Choi H, Hossain N, Munasinghe U, Lakhi F, Lourdusamy D, Onuoha S, Murakonda P, Skokowska-Lebelt A, Kanagala M, Russell RO. Deprescribing as a Clinical Improvement Focus. J Am Med Dir Assoc. Oct 28, 2019.;  

Review
Audiovisual Presentation
Audiovisual Presentation
,
Upcoming Meeting/Conference

Boston Children's Hospital; Institute for Professionalism and Ethical Practice. Deep dive into error disclosure. December 10, 2019, 12:00-2:00 pm (Eastern).;  

Meeting/Conference Proceedings
Newspaper/Magazine Article

Sexton J, Schweber N. The wrong goodbye. ProPublica. October 31, 2019.;  

Upcoming Meeting/Conference
Press Release/Announcement
Tennessee Meeting/Conference
Special or Theme Issue

Periodic Issue
Review
Study

Etherington N, Usama A, Patey AM, Trudel C, Przybylak-Brouillard A, Presseau J, Grimshaw JM, Boet S. Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. BMJ Open Qual. Aug, 2019;8(3):e000686.;  

Government Resource
Newspaper/Magazine Article
Book/Report
Multi-use Website

Accreditation Council for Graduate Medical Education, American College of Surgeons, Association of Program Directors in Surgery and American Board of Surgery.;  

Audiovisual Presentation

Periodic Issue
Study
Review
Newspaper/Magazine Article
Book/Report
Commentary
Government Resource
Congressional Testimony
Grant Announcement

WebM&M

Web M&M Edition November 2019
WebM&M Cases
Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation
Caitlin E. Kulig, PharmD and Imo A. Ebong, MBBS, MS,  
A young woman is admitted with abdominal pain, nausea, and weakness and found to have a urinary tract infection and was started on intravenous levofloxacin. She also received her home medications, which included lithium and an atypical antipsychotic (quetiapine) along with lithium for bipolar disease and multiple doses of intravenous ondansetron and metoclopramide as treatment for nausea. Subsequently, she was observed to be bradycardic with a widening QRS complex on telemetry and became pulseless and unresponsive. Luckily, advanced cardiac life support was implemented with a return of heartbeat and circulation. The use of common medications that caused QT prolongation contributed to this adverse event.
Missed Opportunities for Suicide Risk Assessment
Spotlight Case
CE/MOC
Glen Xiong, MD and Debra Kahn, MD,  
Two different patients were seen in the emergency department a history of excessive alcohol consumption and suicidal ideation along with other medical comorbidities. In both cases, acute medical conditions prevented a comprehensive psychiatric evaluation being completed by psychiatric emergency services. Unfortunately, both patients were discharged after resolution of their medical conditions and were later found dead.
Complications of Vascular Access Procedures in Patients with Kidney Disease
Sierra Rayne Young, Pharm.D. and Iris Chen, Pharm.D., BCPS, BCOP,  
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.