New Case Studies and Research Highlights From AHRQ’s Patient Safety Network
Two new Web M&M (Morbidity & Mortality Rounds on the Web case studies from AHRQ’s Patient Safety Network (PSNet) include expert analyses of medical errors submitted by PSNet users. In one case, a 7-year-old girl with esophageal stenosis died after developing cardiac arrest while undergoing upper endoscopy with esophageal dilation.
The case underscores the importance of communicating between providers and following the necessary technical steps to mitigate the risks of upper endoscopy in children. In another case, a 31-year-old woman was found to have a rare cystic lung disease more than two weeks after her condition was initially misdiagnosed in an emergency department. This case highlights the importance of performing computerized tomography scans for evaluating spontaneous pneumothorax and educating providers to increase awareness of rare cystic lung diseases.
AHRQ's Patient Safety Network (PSNet) features a new set of articles including:
- Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals.
- Improving diagnostic performance through feedback: the Diagnosis LearningCycle.
- CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.