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June 2015
Perspectives on Safety icon
Perspectives on Safety
Organizations Working to Improve Quality and Safety
INTERVIEW
In Conversation With… Maureen Bisognano
Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about IHI's efforts to improve health care on a global level.
(.MP3 | 13.1 MB)
INTERVIEW
In Conversation With… Christine Cassel, MD
Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.
(.MP3 | 11.0 MB)
Cases & Commentaries
SPOTLIGHT CASE
After multiple visits to both his primary care provider and urgent care for chronic burning left foot pain attributed to peripheral neuropathy, a man presented to the emergency department with worsening symptoms. His left lower leg was dusky and extremely tender, with non-palpable pulses. CT angiography revealed complete blockage of the left superficial femoral artery due to atherosclerotic peripheral arterial disease. The patient required emergent vascular bypass surgery on his left leg, and ultimately, an above-the-knee amputation.
Commentary by Edward Etchells, MD, MSc
CME/CEU credit available for this case

Admitted to the hospital with a small bowel obstruction and ileitis consistent with an exacerbation of Crohn disease, a man was given empiric antibiotic therapy and infliximab prior to consultation with gastroenterology. Gastroenterology recommended sending stool studies and initiating infliximab only after those studies were negative for infection. The stool studies were sent, but the primary team did not discontinue the infliximab. The patient was found to have Clostridium difficile infection.
Commentary by Frank I. Scott, MD, MSCE, and Gary R. Lichtenstein, MD

A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.
Commentary by Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN
Photograph of doctor using a computer
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