Perspectives on Safety
CLER and I-PASS
INTERVIEW
Dr. Nasca is CEO of the Accreditation Council for Graduate Medical Education, the major accreditor of residency and fellowship training programs, and CEO of ACGME International. We spoke with him about ACGME's Clinical Learning Environment Review (CLER) program and its impact on medical education.
INTERVIEW
Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.
WebM&M Cases
- SPOTLIGHT CASE
- CME/CEU
Commentary by Patricia Juang, MD, and Kristen Kulasa, MD
While hospitalized, a man with diabetes had difficult-to-control blood sugars, with multiple episodes of both critical hypoglycemia and serious hyperglycemia. Because "holds" of the patient's insulin were not clearly documented in the electronic health record and blood sugar readings were not uploaded in real time, providers were unaware of how much insulin had actually been given.
Commentary by Michael E. Detsky, MD, MSc
During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.
Commentary by Jeanne M. Farnan, MD, MHPE
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.
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