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Time 2020-06-29 21:02:41

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Commentary COVID-19: patient safety and quality improvement skills to deploy during the surge. Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2020. Education is “predictably disappointing” and should never be relied upon alone to improve safety. ISMP Medication Safety Alert! Acute care edition. June 4, 2020;25(11). The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss. CRICO Strategies. July 14, 2020. 1:00-2:00 PM (eastern). A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift. Janeane Giannini, PharmD, Melinda Wong, PharmD, William Dager, PharmD, Scott MacDonald, MD, and Richard H. White, MD ,   June 2020 A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion. The commentary discusses the challenges associated with prescribing direct-action oral anticoagulants (DOACs) and how computerized clinical decision support tools can promote adherence to guideline recommendations and mitigate the risk of error, and how tools such as standardized teaching materials and teach-back can support patient understanding of medication-related instructions. Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this case, a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure to validate a young woman’s complaints resulted in a 12-year diagnostic delay and significant physical and psychologic morbidity. This piece discusses the impact that COVID-19 has had on the services provided by pharmacists and highlights available resources to support them in ensuring medication safety. Anna Legreid Dopp is the Senior Director of Clinical Guidelines and Quality Improvement at the American Society of Health-System Pharmacists (ASHP). We spoke with her about how pharmacist care delivery services have been impacted by COVID-19. This piece discusses the role of the Food and Drug Administration in ensuring the safety of medical devices. Interview In Conversation With... Jeffrey Shuren, MD, JD May 2020 Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food and Drug Administration. We spoke with him about the role of the Food and Drug Administration in ensuring the safety of medical devices. Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. Source: Wong A, Rehr C, Seger DL, et al. Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit. Drug Saf. 2019;42:573-579. [go to PubMed] American Society for Healthcare Risk Management. October 11-14, 2020, The Phoenix Convention Center, Phoenix, AZ.

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