WebM&M Cases
- SPOTLIGHT CASE
- CME/CEU
Commentary by Maria J. Silveira, MD, MA, MPH
An older man with multiple medical conditions was found hypoxic, hypotensive, and tachycardic. He was taken to the hospital. Providers there were unable to determine the patient's wishes for life-sustaining care, and, unaware that he had previously completed a DNR/DNI order, they placed him on a mechanical ventilator.
Commentary by John Q. Young, MD, MPP
Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.
Commentary by Steven L. Cohn, MD
When a pregnant woman with fever, nausea, and headaches presented to the emergency department (ED), laboratory tests showed an incredibly high white blood cell count. Although the ED contacted the hematology service for a consultation, the urgency of the patient's clinical status was not conveyed, leading to a fatal delay in diagnosing and treating her acute myeloid leukemia.
Perspectives on Safety
Certification in Patient Safety
INTERVIEW
Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.
PERSPECTIVE
Karen Frank, DNP, RN, MSHA
This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.
PERSPECTIVE
Zahra Khudeira, PharmD
In this piece, a pharmacist highlights the importance of earning patient safety certification.
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