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

Check Twice, Transport Once

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures.  In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray.  The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Management of Cardiac Arrest in Unconventional Locations

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations—inside of a computed tomography (CT) scanner and at an outpatient transplant clinic—and strategies to ensure that all health care teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Perspectives on Safety

Identifying Safety Events in the Prehospital Setting

This Perspective essay and interview, focuses on measuring and monitoring patient safety in the prehospital setting, which brings a unique set of challenges and opportunities.  Emergency medical services (EMS) personnel provide care outside of a health care facility in complex environments.  The unpredictability of the scene, environmental issues like lighting (or lack thereof), and the need to make decisions for time-sensitive conditions with often incomplete information are just a few of the factors that contribute to the challenge of providing care in the prehospital setting.  Given the complex challenges involved, leaders in the field are developing novel ways to improve measurement and monitoring of patient safety in the prehospital setting.


Clinical Pharmacy Specialists Provide Transitional Care and Improve Medication Safety After Discharge at Memphis Veterans Affairs Medical Center

Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading to hospital readmission in the United States.  To improve medication-related safety and reduce hospital readmissions, the Memphis Veterans Affairs Medical Center (VAMC) started a transitional care clinic (TCC) led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after they are discharged from the hospital or emergency department (ED).

The Duke Pediatric Residency Safety Council

Medical residents, alongside interns, nurses, and attending physicians, are uniquely positioned to identify safety concerns because they are on the front lines of patient care.  To increase resident participation in safety activities and enhance their patient safety training, pediatric residents at Duke Health formed a resident-led safety council, the Duke Pediatric Residency Safety Council.  The council’s activities have included participating in departmental and institutional safety efforts, offering trainings on the topic of patient safety, reviewing and discussing safety event reports, and facilitating in-depth morbidity and mortality conferences on cases and issues of interest.