NYSDA Publications

AHRQ Issues Patient Safety Morbidity and Mortality Report

The Agency for Healthcare Research and Quality (AHRQ) has issued its latest Patient Safety Morbidity and Mortality Report.  You can read the latest AHRQ Patient Safety Morbidity and Mortality Report below.

WebM&M Cases & Commentaries

Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations

This WebM&M spotlight case with CE/MOC, describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease.  The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.  The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients with chronic pain, challenges in opioid dose conversions, and increasing patient safety through safe medication prescribing and thorough medication reconciliation.

Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome

In this WebM&M spotlight case with CE/MOC, a 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections.  He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware.  On physical examination, his neck was tender, but he had no neurologic abnormalities.  He was sent home from the clinic with advice to take over-the-counter analgesics.  Over the next several days, the patient was evaluated for the same or similar symptoms again by his PCP and was seen by the emergency department and urgent care clinics before being admitted to the hospital; however, he was misdiagnosed with Staphylococcal meningitis, and it was not until his third inpatient day when cervical magnetic resonance imaging (MRI) showed a spinal epidural abscess.  The commentary discusses the multiple factors leading to erroneous interpretation tests for spinal epidural abscess and the importance of broadening differentials and avoiding premature closure during diagnosis.

Emerging Innovations

Emerging innovations are an exciting new type of content on PSNet.  They are original approaches to patient safety recently published in the peer-reviewed literature.  We will be releasing “bundles” of Emerging Innovations throughout the year.  This month, we will be featuring a complication reporting app, medication administration discrepancies software, and a model to prevent diagnostic errors.

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

Morbidity and mortality (M&M) conferences are standard components of medical training programs yet medical residents underutilize incident reporting systems that feed into M&M conferences.  To encourage incident reporting among residents, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web-based, real-time complication reporting platform to capture complications.

The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis

Medication administration errors are a common source of patient harm.  Developed at Cincinnati Children’s Hospital Medical Center (CCHMC), MED.Safe is an automated software package designed to monitor high-risk intravenous (IV) medications in neonatal intensive care units (NICUs) and identify medication administration discrepancies.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors

The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO).  In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care.  CHOC researchers used these "Great Catches" to identify potential diagnostic errors.

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