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Cases & Commentaries: SEPTEMBER 2008

Surgery/Anesthesia

Medicine

Emergency Medicine

	Weighing In on Surgical Safety SPOTLIGHT CASE Placed in a supine position for induction of general anesthesia, an obese patient experienced loss of oxygen, blood pressure, and pulse, and died.
	Commentary by Jay B. Brodsky, MD; Michael Margarson, MD
	CME/CEU available

	Missed Patient Assignment: Is Anyone There? A computerized tool for assigning patients used in conjunction with tape-recorded signouts leads to a nurse completely missing a patient.
	Commentary by Dean F. Sittig, PhD; Emily Campbell, RN, MS, PhD; Hardeep Singh, MD, MPH

	Emergent Triage Miss A patient with face and tongue swelling (triaged as "urgent") waited several hours before a provider saw her, by which time she was having difficulty breathing. The patient was intubated and admitted to the ICU with a diagnosis of angioedema.
	Commentary by Debbie Travers, PhD, RN


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Perspectives on Safety

	This month: Safety in Academic Medical Centers

	•	In Conversation with... Richard P. Shannon, MD Listen to podcast (.MP3 \| 2.87 MB \| 6:16)

	•	Operationalizing Patient Safety at Academic Medical Centers by Chayan Chakraborti, MD; Marc J. Kahn, MD; N. Kevin Krane, MD

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Patient Safety Network

What's New: Informal staff "water cooler" conversations are a rich source of data for organizational patient safety learning.

Visit AHRQ PSNet for more patient safety news and information

Did You Know?

Distribution of the 312 "never events" reported to the Minnesota Department of Health in 2007-2008

View Source View all DYKs


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