for monthly email newsletter
Perspectives on Safety
Patient Safety Research
In Conversation With… Hardeep Singh, MD, MPH
Dr. Singh has conducted extensive multidisciplinary research supported by the VA, AHRQ, and NIH and is now a nationally recognized expert in electronic health record–related patient safety issues and diagnostic errors. We spoke with him about becoming a patient safety researcher.
Listen to an audio excerpt of the interview
(.MP3 | 9.09 MB)
Promising Areas for Patient Safety Research
by P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH
This piece, written by three leaders in AHRQ's research portfolio, covers future avenues for patient safety research and reviews current AHRQ projects.
Cases & Commentaries
Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.
Margaret C. Fang, MD, MPH
CME/CEU credit available for this case
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP