Latest Issue of AHRQ WebM&M

December 12, 2011    |   By: Calevir

This month, the Perspectives on Safety section covers fall prevention with Ann L. Hendrich, RN, PhD, of Ascension Health. A leading expert on health care-associated falls, who developed one of the most widely used risk assessment tools. Listen to an excerpt online or download a podcast interview.

In the Spotlight Case, “Order Interrupted by Text: Multitasking Mishap,” while entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and forgot to complete the order.

In the second case, “More Treatment-Better Care?,” a patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.

In the third case, “Missing the Point-Eye Injury,” a woman presented to the emergency department (ED) with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision.

You can easily share AHRQ WebM&M content by using the “Email a colleague” feature. Please also visit AHRQ PSNet-a weekly roundup of literature, news, conferences, and tools in patient safety, and the world’s most robust and easily searchable patient safety library.

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More

RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.