WebM&M | AHRQ Patient Safety Network

WebM&M | AHRQ Patient Safety Network

Cases & Commentaries

Dying in the Hospital With Advanced Dementia

• SPOTLIGHT CASE
 
• CME/CEU

Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.

Commentary by Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA

Miscommunication in the OR Leads to Anticoagulation Mishap

Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding.

Commentary by Ian Solsky, MD, and Alex B. Haynes, MD, MPH

Over-the-Counter Oversight

At a preoperative evaluation for skin grafting surgery, a man's prescription medications were reviewed and updated in his medical record. During surgery, the patient experienced profuse bleeding, requiring transfusion with multiple units of blood. Postoperatively, the patient stabilized and the attending surgeon reexamined the patient's medications with him and asked about over-the-counter medications. The patient had been taking one aspirin per day, including the day of surgery. Although the patient was asked about blood-thinning medications at the preoperative visit, he was not asked about over-the-counter medications.

Commentary by Varalakshmi Janamanchi, MD; Kunjam Modha, MD; and Christopher Whinney, MD

Perspectives on Safety

Surgical Safety

INTERVIEW

In Conversation With… Karl Bilimoria, MD, MS

Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.

PERSPECTIVE

The Evolution of Patient Safety in Surgery

This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.