http://webmm.ahrq.gov AHRQ Morbidity and Mortality Rounds on the Web is the online journal and forum on patient safety and health care quality. The site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety, perspectives on safety, and forums for online discussion. CME and CEU credit are available. The site is funded by the Agency for Healthcare Research and Quality, edited by a team at the University of California San Francisco, with the technical support of Silverchair. An editorial board and advisory panel, comprised of experts in patient safety, health care quality, and clinical disciplines, guide the editorial team. en-us Thu, 15 Oct 2009 12:44:13 GMT Thu, 15 Oct 2009 12:44:13 GMT http://blogs.law.harvard.edu/tech/rss ehartman@medicine.ucsf.edu ehartman@medicine.ucsf.edu http://webmm.ahrq.gov/case.aspx?caseID=206 Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene. Thu, 15 Oct 2009 12:44:13 GMT http://webmm.ahrq.gov/case.aspx?caseID=207 A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor. Thu, 15 Oct 2009 12:44:13 GMT http://webmm.ahrq.gov/case.aspx?caseID=208 Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity. Thu, 15 Oct 2009 12:44:13 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=79 Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with the Los Angeles Times, he co-wrote a series of articles about medical errors at Martin Luther King Jr./Drew Medical Center, which closed in 2007; the series earned the newspaper a Pulitzer Prize for Public Service. He is also the president of the Association of Health Care Journalists. We asked him to speak with us about the role of the media in patient safety. This interview was conducted while he was still at the Times. Thu, 15 Oct 2009 12:44:13 GMT http://webmm.ahrq.gov/perspective.aspx?perspectiveID=80 December 1 marks the tenth anniversary of the Institute of Medicine (IOM) report To Err Is Human, the blockbuster that launched the modern patient safety movement. The anniversary provides an opportunity to reflect on the forces that have promoted safety efforts over the past decade. They include a more robust accreditation environment, increased reporting of adverse events to state and other regulatory bodies, growing implementation of information technology, skill-building support by organizations such as Institute for Healthcare Improvement, and a maturing research field supported by AHRQ and others. Thu, 15 Oct 2009 12:44:13 GMT