Blog & Articles

[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.

[8 MIN READ]

“Maternal Death”

The words are bone-chilling. Nothing can describe being witness to it. Such an event encompasses the ultimate emotional spectrum – the highest of highs at the time of the newborn’s birth to the lowest of lows as the mother succumbs to maternal emergency. The lasting impact of watching a new father and family members exit the hospital OB unit or ICU to head home with a new infant in tow with conspicuous absence of the child’s mother creates palpable heartache. The emotional ripple-effect impacts friends, family, and medical staff for years to come.

According to ENA, retrospective chart review is a critical element of ongoing triage competency validation. The RSQ® Solutions – Triage Assessment tool is built upon triage best practices and provides a mechanism through which your organization can implement and execute a scalable and sustainable chart review process.

Using this tool, nursing management can easily assess triage competency on an ongoing basis; it allows them to:

• Determine the accuracy of triage levels assigned by an individual nurse or by the entire department.
• Measure overall improvement in a department’s triage accuracy.

[10 MIN READ]

Have you ever wondered as an Labor and Delivery RN how many hours during your shift you spend staring at fetal heart tracings?

I’ll bet you have never tried to tally such a figure, but I’d venture to guess it encompasses not only a large portion of your daily practice, but an enormous part of your career as well.

During a 12-hour shift of managing labor induction, you could easily spend approximately 5-6 hours or more actually staring at the monitor. That’s 50% of your shift! This translates into the possibility that half of your intrapartum career is immersed in FHR tracings!

This enormity speaks volumes to expectations of your ability to understand and manage the fetal tracing. Your knowledge base should be solidly comprehensive and your ability to articulate standardized definitions rapid. If litigation were ever to knock at your door, would you be able to defend your actions surrounding your interpretation and analysis of the FHR tracing?

Failure to recognize, failure to act, and failure to communicate have been cited as three litigious areas of concern regarding FHR monitoring. Let’s take a look at six common “pitfalls” that can get you into trouble regarding tracing analysis.

In today’s case presentation, we will navigate the difficult waters of patient refusal of life-saving care based upon religious beliefs. In this actual case, a woman’s life hung the balance. There was little time for formal mental status evaluation or communication with legal counsel or a local judge.

It was around 8:30 pm during a busy shift in the Cook County Emergency Department. A young woman had been rolled into the department with low blood pressure.

Providing care to psychiatric patients in the emergency department is a challenge for many reasons.

• Emergency physicians often receive insufficient training in behavioral emergencies.
• ED personnel are uncomfortable evaluating and treating these patients.
• ED staff may harbor negative attitudes toward behavioral health patients.
• Resources such as consultants and inpatient beds are lacking.
• The hectic ED environment can lead to iatrogenic escalation of psychiatric crises.

For the ED, however, the greatest risk and safety issue related to behavioral health is the appropriate evaluation and protection of the suicidal patient in the ED. We present 2 case studies to illuminate the uncommon but preventable catastrophe of suicide in the ED.

Clinicians issue tens of millions of warfarin prescriptions each year in the U.S., despite the increasing use of alternative anticoagulant medications. Practitioners will continue to encounter warfarin, known both for its irreplaceable value and potential for life-threatening complications. Due to the propensity for permanent disability and death from hemorrhagic complications, litigation is common and costly. Knowledge of the pharmacology, indications, monitoring, drug interactions and complications of warfarin is an essential tool to avoid patient harm, medical errors, and the medical-legal vulnerabilities associated with its use.