New Perspectives and WebM&M Cases now available on AHRQ PSNet

New Perspectives and WebM&M Cases now online.

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PSNet 2015

Perspectives on Safety—Patient Safety at 20

This month's interview features Shantanu Agrawal, MD, MPhil, president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.

In the accompanying perspective, Sumant Ranji, MD, and Robert M. Wachter, MD, both of UCSF, explore the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarize changes in the patient safety landscape over time.

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Cases & Commentaries

Spotlight: A Femoral Sheath Fatality
After undergoing a scheduled percutaneous coronary intervention, a man with a femoral sheath still in place was admitted to the medical ward, where several beds had recently been converted to cardiac telemetry beds. Having limited experience with femoral sheaths, the nurse removed it but was unable to assess the patient every 15 minutes as required due to becoming busy with another patient. One hour later the patient was unresponsive, a code was called, and he was transferred to the intensive care unit where he died several hours later. In the commentary, Hildy Schell-Chaple, RN, PhD, of UCSF discusses bleeding events associated with femoral vascular access sheaths used for interventional cardiac diagnostic procedures and highlights how applying a systems approach to practice changes can optimize safety and performance improvement outcomes. (CE/MOC available.)

Getting the Diagnosis Both Right and Wrong
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed. In the accompanying commentary, Andrew P. Olson, MD, of the University of Minnesota Medical School provides an overview of diagnostic reasoning, including the three main types of cognitive biases that lead to diagnostic errors and how interactions between clinicians, patients, and the clinical environment affect the diagnostic process.

Think Like a Surgeon
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess. Zara Cooper, MD, MSc, of Harvard Medical School, describes challenges to diagnosing acute cholecystitis and the importance of early involvement of surgeons where the diagnosis is suspected.

Deadline to obtain WebM&M Continuing Education (CE) Certificates is September 25.
Upcoming changes to AHRQ PSNet require users seeking continuing education (CE) credits to do so by September 25, 2019. The existing Spotlight Case content will not be eligible for CE credit after September 25, 2019. For the widest selection of CE courses, users should obtain course credits by September 25, 2019. Users will still be able to download their CE certificates for previous Spotlight Cases at

Starting in October 2019, new Spotlight Cases will be launched monthly for users to obtain CE credits. AHRQ will support users throughout this process.