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

Intraosseous Line Extravasation in a Pediatric Trauma Patient

In this WebM&M spotlight case with CE/MOC, an 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck.  After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.  An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line.  The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome.  Signs of compartment syndrome eventually resolved without any surgical intervention.  The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

This WebM&M case describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient.  The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.


Post-Acute Transitional Services: Safety in Home-Based Care Programs

Post-acute transitions—which involve patients being discharged from the hospital to home-based or community care environments—are associated with patient safety risks, often due to poor communication and fragmented care.  This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Perspectives on Safety

The Media’s Role in Patient Safety

In this Perspective essay and interview, the PSNet team worked with Michael L. Millenson, President of Health Quality Advisors LLC and an adjunct associate professor of medicine.  We spoke with him about the historical role of traditional media in shaping patient safety efforts and how the role of media has changed over time.  We also discussed examples of social media applied to healthcare settings and the future role of traditional and social media in patient safety.


A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital, like many hospitals around the country, faced many challenges including but not limited to high patient consensus, high patient acuity, scarcity of personal protective equipment and staffing.  Having enough staff to meet the patient care needs at the time was a major concern that was exacerbated by several providers’ need to work at home.  Several hospitalists stayed offsite due to pregnancy, comorbidities, quarantine due to COVID-19 exposure, or recovery from illness.  However, these staff were available to work virtually.  To address patient care needs and staffing shortages, the innovation team launched a virtual hospitalist program to allow staff who could not physically come into the hospital the ability to support the demands for patient care from home.  The virtual hospitalists were able to address patient and family communication, write clinical notes, and train redeployed physicians (physicians that work outside of their specialties in the time of a disaster).  Covering these duties freed up the onsite team to see more patients and focus on bedside clinical management of acutely ill patients.  This innovation summary details their approach to implementation and early results of their work.