AHRQ Web M&M Released

January 20, 2015    |   By: Calevir

The Agency for Healthcare Research and Quality (AHRQ) has released their latest issue of the Web Morbity & Mortality cases and commentaries.   For more information, visit AHRQs website using the links found in the case summaries:

Spotlight Case: Monitoring Fetal Health
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient. The commentary by Mark W. Scerbo, PhD, of Old Dominion University, and Alfred Z. Abuhamad, MD, of Eastern Virginia Medical School, provides an overview of fetal heart rate monitoring, the risks and benefits of this complex process, and factors that influence its safety such as staff training and safety culture. (CME/CEU credit available.)

Bowel Injury After Laparoscopic Surgery
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia. In the accompanying commentary, Krishna Moorthy, MD, MS, of Imperial College London, discusses safety hazards in laparoscopic surgery and practices to reduce risks including protocol-based care and nontechnical skills like teamwork, communication, and leadership.

Haste Makes Care Unsafe
While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication. John Eichhorn, MD, of the University of Kentucky, examines how communication breakdowns and production pressure can cause adverse outcomes and highlights how checklists can help prevent mistakes.

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