September 25, 2014 | By: Calevir
The Agency for Healthcare Research and Quality (AHRQ) has released their latest issue of WebM&M (“morbidity & mortality rounds on the webâ€). AHRQ case topics include:
A Lot of Pain (Medications) – Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called. Read the full case and commentary
Too Much, Too Fast – A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful. Read the full case and commentary
No BP During NIBP – A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned. Read the full case and commentary
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
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
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
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