AHRQ Releases Latest M&M Cases

March 7, 2013    |   By: Calevir

The Agency for Healthcare Research & Quality (AHRQ) has released its three latest M&M cases from which lessons can be learned to improve patient safety.

#1 – Incorrect documentation of a toddler’s weight as 25 kg instead of 25 lbs, leading to an error in calculating the appropriate antibiotic dosage. ¬† Information focuses on the risks of weight-based dosing, data entry errors and automation complacency with free CME, CEU or trainee certification for taking the quiz.

#2 – how to avoid errors related to the use of unfamiliar devices, highlighting a nurse’s failure to clamp the post-lung transplant patient’s large-bore central line after drawing labs, allowing air to enter the catheter.

#3 Р Inaccurate pathology report which changed diagnosis from an unusual lymphoproliferative disease to adult-onset celiac disease.

Also learn from physicians at Stanford and the Mayo Clinic about the introduction of the modern full-body patient simulator and the use of crew resource management (TeamSTEPPS) training used to improve the delivery of care.

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.