AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

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AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

May Issue of AHRQ’s WebM&M Is Now Available
The May issue of AHRQ’s WebM&M explores how trigger tool methods to quantify levels of harm have transformed patient safety measurement.  The Perspectives on Safety interview features David C. Classen, M.D., Associate Professor of Medicine at the University of Utah, and a leading developer of the Institute for Healthcare Improvement’s global trigger tool. In the accompanying perspective, Paul J. Sharek, M.D., Stanford University School of Medicine, outlines how the trigger tool approach helps to identify adverse events more efficiently than other detection methods.  The Spotlight Case provides an example of how inadequate sign-out prevented members of a night float team from understanding a patient's mental status changes, causing a prolonged stay in the intensive care unit.  The commentary, written by Jeanne M. Farnan, M.D., and Vineet M. Arora, M.D., both of the University of Chicago, details the growing need for standardized handoff communication in the wake of 2011 changes to the Accreditation Council for Graduate Medical Education’s  duty hours regulations.  Physicians and nurses can receive free CME, CEU, or trainee certification by taking the Spotlight Quiz. 
AHRQ WebM&M: Morbidity & Mortality Rounds on the Web

Cases & Commentaries

SPOTLIGHT CASE

The Perils of Cross Coverage

Inadequate signout to the members of the night float team prevented them from appreciating a patient's mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay.
Commentary by Jeanne M. Farnan, MD, MHPE; and Vineet M. Arora, MD, MAPP

CME/CEU credit available for this case

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Double Dose at Transfer

Diagnosed with cellulitis, an elderly man was admitted to the hospital after receiving the first dose of vancomycin in the ED. Just 3 hours later, a floor nurse noted the admission order for vancomycin every 12 hours and administered another dose.
Commentary by Jeffrey L. Hackman, MD

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The Forgotten Line

After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.
Commentary by Marta L. Render, MD

Perspectives on Safety

Trigger Tools

INTERVIEW

In Conversation With…David C. Classen, MD, MS
One of the pioneers of the trigger tool methodology for detecting adverse events, Dr. Classen is Chief Medical information Officer at Pascal Metrics and Associate Professor of Medicine at the University of Utah.

Listen to an audio excerpt of the interview

(.MP3 | 14.5 MB)

PERSPECTIVE

The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety
by Paul J. Sharek, MD, MPH

This piece explains how the trigger tool approach identifies adverse events more efficiently than other detection methods such as voluntary incident reporting and patient safety indicators drawn from administrative data.

 

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