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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: Anchoring Bias With Critical Implications
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.
CASE AND COMMENTARY: Inflicting Confusion
Admitted to the hospital with a small bowel obstruction and ileitis consistent with a Crohn disease flare, a man was given empiric antibiotics and infliximab prior to gastroenterology consult. 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 infection.
CASE AND COMMENTARY: Unseen Perils of Urinary Catheters
A hospitalized older man with a complicated medical history had not voided in several hours. The hospitalist ordered insertion of a urinary catheter. Just prior to insertion the patient voided and inserting the catheter produced no urine, but 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 discovered the urinary catheter was not in the bladder.
In Conversation with...Maureen Bisognano
Maureen Bisognano is President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI). We spoke with her about IHI's efforts to improve health care on a global level.
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.

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