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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: Errors in Sepsis Management
An older woman with a history of pulmonary hypertension, chronic obstructive pulmonary disease (COPD), and coronary artery disease was admitted to the hospital with pneumonia. She received levofloxacin (administered approximately 3 hours after presentation). Twenty-four hours after admission, her blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin was added to her antibiotic regimen. The patient developed respiratory failure requiring mechanical ventilation as well as septic shock requiring vasopressors.
CASE AND COMMENTARY: Transitions in Adolescent Medicine
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the emergency department with abdominal pain and was found to be pregnant. It was her second pregnancy; she had a therapeutic abortion 4 years earlier due to the risk of aortic rupture during pregnancy. At that time, the patient had been advised to have her aortic root surgically repaired in the near future. However, after the patient turned 18, she did not receive regular follow-up care or pre-conception or contraception counseling despite the risk to her health should she become pregnant.
CASE AND COMMENTARY: Departure From Central Line Ritual
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
In Conversation with...John D. Birkmeyer, MD
Dr. Birkmeyer is Chief Academic Officer and Executive Vice President at Dartmouth-Hitchcock Medical Center. We spoke with him about his seminal video study that found a link between practicing surgeons' directly observed technical skills and surgical outcomes.
Video to Improve Patient Safety: Clinical and Educational Uses
This piece explores the advantages of using video in clinical practice and health care education to augment safety and quality.

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