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

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

June Issue of AHRQ Web M&M Examines Impact of Delayed Communication  

The June 2012 issue of AHRQ Web M&M features a Spotlight Case involving delayed communication between a small community hospital and a large academic medical center involving a 92-year-patient with a hip fracture. Although the patient was stable upon admission to the academic medical center and underwent surgery to repair the fracture, she died a few days thereafter. Following her operation, the team received medical records from the referring hospital that indicated the patient had recently experienced a cardiac arrest, information that would have changed the course of her treatment. A commentary on the case is provided by Isla M. Hains, Ph.D., a faculty member at the University of New South Wales, Sydney, Australia. The Perspectives on Safety section features an interview with Charles Vincent, MPhil, Ph.D., who directs the Imperial Center for Patient Safety and Service Quality at Imperial College, London. Physicians and nurses can receive free CME, CEU, or training certification by taking the Spotlight Quiz. Select to access AHRQ’s Web M&M site. 

Cases & Commentaries

SPOTLIGHT CASE

Transfer Troubles

An elderly woman was transferred to a tertiary hospital for surgical repair of hip fracture, without complete information or records. The receiving surgeons were not informed that she had a cardiac arrest during induction of anesthesia at the community hospital. Surgery proceeded, but the patient died a few days later.
Commentary by Isla M. Hains, PhD

CME/CEU credit available for this case

---

A Painful Dilemma

A woman with end-stage renal disease, who often skipped dialysis sessions, was admitted to the hospital with fever and given intravenous opiates for pain. Because her permanent arteriovenous graft was clotted, she had been receiving dialysis via a temporary femoral catheter, increasing her risk for infection. Blood cultures grew yeast; the patient was diagnosed with fungal endocarditis, likely caused by injections of opiates through her catheter.
Commentary by Sara N. Davison, MD, MHSc

---

Comanagement: Who’s in Charge?

Following surgery for hip fracture, an elderly man with a history of chronic obstructive pulmonary disease developed worsening shortness of breath. At this hospital, the orthopedic surgery service has hospitalists comanage its patients. Inadequate communication between the services led to a delay in diagnosing the patient with pneumonia and initiating treatment.
Commentary by Hugo Q. Cheng, MD

 

Safety in the UK

INTERVIEW

In Conversation With… Charles Vincent, MPhil, PhD
Professor Vincent, a psychologist by training, is one of the world’s leading patient safety researchers.

Listen to an audio excerpt of the interview

(.MP3 | 13.5 MB)

PERSPECTIVE

An American View of the UK’s Patient Safety Enterprise: Top Down vs. Bottom Up
by Robert M. Wachter, MD

This piece examines differences in the patient safety movements in the UK and US, as seen through the eyes of an American safety expert who spent 6 months in England last year.

News from AHRQ Patient Safety Network

National Quality Forum releases new consensus standards for patient safety measures.

Visit AHRQ PSNet for patient safety news & info