May 2013
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Perspectives on Safety
Pay-for-Performance: Implications for Patient Safety
INTERVIEW
In Conversation With… Ashish K. Jha, MD, MPH
Harvard internist Dr. Jha is a national leader in policy issues related to safety and quality.
Listen to an audio excerpt of the interview
(.MP3 | 12.0 MB)
PERSPECTIVE
Strengthening the Business Case for Patient Safety
by Peter K. Lindenauer, MD, MSc
This piece discusses efforts to promote the business case for safety and quality in health care.
Cases & Commentaries
SPOTLIGHT CASE
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
Commentary by
Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD
CME/CEU credit available for this case
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
Commentary by
B. Joseph Guglielmo, PharmD
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
Commentary by
Roy Ilan, MD, MSc