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


Debriefing for Clinical Learning

Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance.  It is one of the central learning tools in simulation training and is also recommended after significant clinical events.  This updated PSNet primer includes an overview of common debriefing methodologies and phases, geared toward health care professionals new to clinical debriefing.

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

In this WebM&M spotlight case with CE/MOC, a 77-year-old man was diagnosed with a rectal mass, presumed secondary to locally advanced cancer.  After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up.  The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain.  Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible.  The inpatient hospice team discussed the potential role of brain radiotherapy for palliation to meet the goal of maintaining independence.  The patient successfully completed a course of central nervous system (CNS) radiation, which resulted in improved strength, energy, speech, and quality of life.  This case represents a perceived delay in palliative radiation, an “error” in care.  The impact of the delay was lessened by the hospice team who role modeled integration of disease directed therapy with palliative care, a departure from the historic model of separation of hospice from disease treatment.

Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery

In this WebM&M case, a 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation.  During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery.  Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.  After delivery, the patient was transferred to the post-anesthesia care unit (PACU) and monitored for 90 minutes, after which she was deemed stable, despite some abnormal vital signs.  All monitor alarm functions were silenced to help the patient rest until a bed became available on the maternity floor.  After another 90 minutes, the patient’s nurse discovered her unresponsive and the bedsheets were blood-soaked.  A massive transfusion was ordered and uterotonic medications were administered, but vaginal bleeding continued.  During an emergency laparotomy, the uterus was noted to be atonic despite uterotonic therapy, requiring an emergency hysterectomy.  The commentary discusses the importance and use of early maternal warning systems, checklists and protocols to avoid poor maternal outcomes.