AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
www.ahrq.gov
Cases & Commentaries
SPOTLIGHT CASE
Admitted with a congestive heart failure exacerbation, an elderly man acquired an infection around his peripheral IV site, accompanied by fever, chills, and back pain. Likely secondary to the infected peripheral IV catheter, the patient had developed methicillin-resistant
Staphylococcus aureus bacteremia and an epidural abscess.
Commentary by
Chi-Tai Fang, MD, PhD
CME/CEU credit available for this case
Prior to surgery, failure to transmit information about a man whose blood glucose level fell precipitously after receiving insulin, combined with the fact that the electronic health record (EHR) had not been updated with current glucose levels, led to another dangerous drop in the patient's glucose level.
Commentary by
Allan Goldman, MB, and Ken Catchpole, PhD
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
Commentary by
Robert R. Cima, MD, MA
Perspectives on Safety
Nurse Staffing and Patient Safety
INTERVIEW
In Conversation With… Jack Needleman, PhD
Prof. Needleman has performed some of the key studies on how the nursing workforce influences health outcomes, including seminal articles published in the New England Journal of Medicine in 2002 and 2011.
(.MP3 | 12.0 MB)
PERSPECTIVE
Preparing for Health Reform: The Federal Government and the Nursing Workforce
by Peter I. Buerhaus, PhD, RN
This piece describes federal initiatives aimed at preparing the nursing workforce needed to match future demand and to navigate changes vital to improving health care.
Did You Know?
AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
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