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.

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