Perspectives on Safety
Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature
INTERVIEW
Dr. Shojania is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto. We spoke with him about the evolution of patient safety research over the past 15 years.
INTERVIEW
Ms. Zipperer was a founding staff member of the National Patient Safety Foundation as their information projects manager and has also been Cybrarian for AHRQ Patient Safety Network since its inception. We spoke with her about the role of librarians in patient safety.
PERSPECTIVE
Robert M. Wachter, MD
This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.
WebM&M Cases
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
- SPOTLIGHT CASE
- CME/CEU
Commentary by Jacob Reider, MD
After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.
Did You Know?
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