ACOG has issued a practice advisory regarding the recent measles outbreak.
Blog & Articles
[12 MIN READ]
While the mission of clinical research is to advance the practice of medicine, it is an extremely daunting task to not only manage clinical trials, but to also oversee them to keep patients safe and reduce risk. In a review of numerous malpractice cases related to clinical research, I have found several common denominators and opportunities to improve patient safety.
The issues that arise from clinical trials are not typically intentional; they are simply intrinsic to the complexities of the system. Under the best of circumstances and in many cases by design, patients have significant problems and are randomized to receive a trial drug. This population is inherently at risk. Additionally, many medical professionals are not trained to conduct appropriate, safe, well-organized clinical trials. These factors along with others I will outline have led to an increase in patient injury, federal and legal scrutiny, and obviously, litigation.
[6 MIN READ]
The Joint Commission (TJC) defines a Sentinel Event as “a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm and intervention required to sustain life.” TJC adopted a Sentinel Event Policy in 1996 in an effort to assist hospitals in voluntarily reporting, evaluating and reducing risk, and preventing patient harm. The term “never event” was first described in 2001 by Dr. Kenneth Kizer of The National Quality Forum (NQF) in reference to significant adverse medical errors that should never have taken place. The NQF currently uses this term when referring to serious reportable events deemed preventable. Whatever you choose to call these, they are simply events that really should not happen.
[4 MIN READ]
Your Postpartum Patient
Your postpartum patient was not complaining. Her vital signs were stable. She had experienced a prolonged labor, but to your knowledge, her vaginal delivery the previous day went well. Her recovery seemed to be progressing nicely. The morning report did not reveal that she was at any risk.
[2 MIN READ]
The development of tools and resources to guide the busy practitioner in prescription decision-making is a welcome trend in healthcare, particularly when the information is instantly available from valuable sources, including Prescription Drug Monitoring Programs and the patient’s medication history. As outlined recently by Ms. Caldwell on the MEDHOST blog, marrying these resources into the prescription functionality of an EHR is a key component in the effort to combat the opioid crisis.
We've featured a variety of topics, cases, and missed diagnoses on our blog this year, and we hope that you've found the content useful and relevant.
In case you missed some of 2018's most popular posts, here are the top 10 articles from the blog this year, according to our website visitor statistics. Which article is most valuable to you?
[3 MIN READ]
The risks we face as acute care practitioners are not static—they evolve over time. Just as we master the approach to a longstanding high-risk problem, a new risky patient presentation rears its head to challenge us. Consider ectopic pregnancy. Now that we routinely obtain pregnancy tests on all women from age 10 to 60 and have access to or skills in ultrasound, the evaluation of possible ectopic pregnancy has become largely an algorithmically routine matter, and errors involving ectopic pregnancy have plummeted as a result.
[3 MIN READ]
Correct patient identification has long been at the top of the list regarding safety.
A recent TSG article by Dr. Tom Syzek entitled “Medical Errors, Communication, Teamwork and End of Life: Lessons from Angola” speaks to the importance of correct patient identification and the safety implications surrounding it. This article dovetails nicely with the new 2019 Joint Commission National Patient Safety Goal (NPSG) regarding newborn identification, so I thought this would be the perfect opportunity to keep the conversation relevant and on-topic by addressing this new NPSG.
[6 MIN READ]
(adapted with permission from the original by Dr. Tim Kubacki at https://kubackisinangola.com/)
Dr. Tom Syzek: These days we hear so much about the importance of communication and teamwork in avoiding medical errors and how we deliver care at the end of life, I thought for perspective, I would share this case presentation from Dr. Tim Kubacki. Tim is a friend and colleague who left behind the comfortable life of an emergency physician in central Ohio to serve with his family as a medical missionary for 6 years in the jungle interior of Brazil, and for the past 5 years in medically underserved rural Angola. Tim recounts beautifully this medical case of mistaken identity, driving home the point that communication and teamwork are the essence of patient safety, while at the same time describing the only “end-of-life care” available.
In 2014, there were 885 million physician office visits. Over half of these visits occurred in primary care –family medicine, internal, medicine, pediatrics and others – but there are still hundreds of millions of visits to medical and surgical specialists as well.
Based on information available from journal publications and claims data, we assembled this list of the top ten risk and safety issues pertinent to ambulatory care settings. While this list is not exhaustive, it represents the majority of errors and pitfalls in ambulatory patient safety.