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New Online Resource Combines Patient Safety News, Research and Resources

AHRQ has merged its Patient Safety Network (PSNet) and AHRQ WebM&M (Morbidity and Mortality Rounds on the Web) to help readers more efficiently access patient safety news, research and expert commentary. PSNet combines all the features of and content from both sites, including PSNet weekly updates, WebM&M Cases and Commentaries, Perspectives on Safety (including podcasts), Patient Safety Primers, The PSNet Collection and more.

Journal Article

The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.

White WA, Kennedy K, Belgum HS, Payne NR, Kurachek S. Jt Comm J Qual Patient Saf. 2015;41:550-562.

The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study.

Heyland DK, Ilan R, Jiang X, You JJ, Dodek P. BMJ Qual Saf. 2015 Nov 9; [Epub ahead of print].

Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.

Mazor K, Roblin DW, Greene SM, Fouayzi H, Gallagher TH. BMJ Qual Saf. 2015 Nov 3; [Epub ahead of print].

Enhancing surgical safety using digital multimedia technology.

Dixon JL, Mukhopadhyay D, Hunt J, Jupiter D, Smythe WR, Papaconstantinou HT. Am J Surg. 2015 Oct 22; [Epub ahead of print].

Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute of Medicine.

McGlynn EA, McDonald KM, Cassel CK. JAMA. 2015 Nov 16; [Epub ahead of print].

What is the role of individual accountability in patient safety? A multi-site ethnographic study.

Aveling EL, Parker M, Dixon-Woods M. Sociol Health Illn. 2015 Nov 4; [Epub ahead of print].

Relationship between patient safety climate and standard precaution adherence: a systematic review of the literature.

Hessels AJ, Larson EL. J Hosp Infect. 2015 Sep 25; [Epub ahead of print].

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.

Stocks SJ, Kontopantelis E, Akbarov A, Rodgers S, Avery AJ, Ashcroft DM. BMJ. 2015;351:h5501.

Diagnostic errors related to acute abdominal pain in the emergency department.

Medford-Davis L, Park E, Shlamovitz G, Suliburk J, Meyer AND, Singh H. Emerg Med J. 2015 Nov 3; [Epub ahead of print].

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

Payne TH, Hines LE, Chan RC, et al. J Am Med Inform Assoc. 2015;22:1243-1250.

Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills.

Gardner AK, Abdelfattah K, Wiersch J, Ahmed RA, Willis RE. J Surg Educ. 2015 Sep 8; [Epub ahead of print].

Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews.

Samra R, Bottle A, Aylin P. BMJ Open. 2015;5:e008128.

The safety of emergency medicine.

Ramlakhan S, Qayyum H, Burke D, Brown R. Emerg Med J. 2015 Nov 3; [Epub ahead of print].

Book/Report

Continuous Improvement of Patient Safety: The Case for Change in the NHS.

Illingworth J. London, UK: The Health Foundation; 2015. ISBN: 9781906461706.

Beyond the Quick Fix: Strategies for Improving Patient Safety.

Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto; 2015.

Special or Theme Issue

Simulation-based Surgical Education.

Surgery. 2015;158:1395-1440.

Also of Note

Integrating Quality Improvement Methods to Improve Teamwork and Patient Safety.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. December 9, 2015; 1:00–2:00 PM (Eastern).

Sentinel Event Statistics 1995–2015.

The Joint Commission.

Perspectives on Safety

Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature

INTERVIEW

In Conversation With… Kaveh Shojania, MD

Dr. Shojania is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto. We spoke with him about the evolution of patient safety research over the past 15 years.

INTERVIEW

In Conversation With… Lorri Zipperer, MA

Ms. Zipperer was a founding staff member of the National Patient Safety Foundation as their information projects manager and has also been Cybrarian for AHRQ Patient Safety Network since its inception. We spoke with her about the role of librarians in patient safety.

PERSPECTIVE

Introducing the Redesigned AHRQ Patient Safety Network

Robert M. Wachter, MD

This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.

View all Perspectives

WebM&M Cases

The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy

• SPOTLIGHT CASE
 
• CME/CEU

Commentary by Jacob Reider, MD

After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.

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An Obstructed View

Commentary by Jonathan Carter, MD

A patient with severe abdominal pain was admitted to the medicine service for observation, pain control, and serial abdominal examinations. Surgical consultation was not requested at admission. Two days later, the patient's abdomen worsened. Consultation led to urgent surgery, which revealed a strangulating bowel obstruction and associated perforation.

Amphotericin Toxicity

Commentary by Jerod Nagel, PharmD, and Eric Nguyen

A woman who had recently had her left lung removed for aspergilloma presented to the outpatient clinic with pain, redness, and pus draining from her sternotomy site. She was admitted for surgical debridement and prescribed IV liposomal amphotericin B for aspergillus. Hours into the IV infusion, the patient developed nausea, vomiting, sweating, and shivering, and it was discovered that she had been given conventional amphotericin B at the dose intended for the liposomal formulation, representing a 5-fold overdose.

View all WebM&M Cases