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The Patient Safety Group has compiled the latest in health, quality, and safety, news and reports.


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SPOTLIGHT CASE AND COMMENTARY: A Stroke of Error
An elderly man admitted for a presumed hypertensive emergency and undiagnosed neurologic symptoms became unresponsive and was noted to have new right hand weakness 2 days into his hospitalization. After a "Code Stroke" was called, a neurologist evaluated him and administered tPA 100 minutes after the acute event. A few hours later, the patient developed further symptoms, and an emergent head CT demonstrated post-tPA intracerebral hemorrhage.
CASE AND COMMENTARY: Ebola: Are We Ready?
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.
CASE AND COMMENTARY: Medical Devices in the "Wild"
An elderly man was being prepared for discharge after being hospitalized for an exacerbation of congestive heart failure. His nurse failed to notice that the tubing of the patient's sequential compression devices (in place to prevent DVT) was caught on the bed wheel and had unlocked the bed when she raised it. When the patient attempted to get up later, the bed rolled out from under him and he fell, breaking his hip. One week after surgery, the patient experienced a cardiac arrest from a massive pulmonary embolism and died.
In Conversation with...Edward Kelley, PhD
Dr. Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). We spoke with him about his work with WHO and the global impact of the organization on patient safety.
African Partnerships for Patient Safety: Lessons Learned
This piece describes the evolution of the World Health Organization's African Partnerships for Patient Safety program and its implications for global patient safety improvement.

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