JAMA Performance Improvement: Do No Harm

From the JAMA Network, this is JAMA Performance Improvement: Do No Harm, the podcast about performance improvement and medicine that aims to elevate the quality of care, one patient at a time, with host Ed Livingston, MD.
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JAMA Performance Improvement: Do No Harm





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Now displaying: 2017
Dec 26, 2017

It is very easy to confuse drug concentrations and vials containing different amounts of drugs in the hospital setting. It is not uncommon to have dosing errors occur. In this podcast, we discuss how to manage an overdose of insulin and also how to implement preventive measures in the hospital environment to minimize the risk of drug dosing errors. Interviewees include Cynthia Barnard, PhD, MBA, MSJS, from Northwestern Memorial HealthCare, Lara K. Ellinger, PharmD, BCPS, from Northwestern Memorial Hospital, and Keith Hemmert, MD, from Northwestern Memorial HealthCare.

Read the article: Insulin Dosing Error in a Patient With Severe Hyperkalemia


Nov 28, 2017

There are about 500 wrong-site surgeries performed in the United States every year. Simple maneuvers can minimize the risk for these occurring. This JAMA Performance Improvement podcast reviews a case of wrong-site surgery and discusses potential ways to avoid it.

Interviewees include Armando Giuliano, MD, Harry Sax, MD, Kathryn Englehart, MD, and David Baker, MD, from The Joint Commission.

Read the article: Wrong-Site Surgery

Author Affiliations:

Armando Giuliano, MD, Executive Vice Chairman, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles

Harry C. Sax, MD, Executive Vice Chair, Administration Department of Surgery, Cedars-Sinai Medical Center, Los Angeles

Kathryn Englehart, MD, Research Fellow, Department of Surgery, Northwestern University

David Baker, MD, Executive Vice President, Division of Health Care Quality Evaluation, The Joint Commission


Jun 20, 2017

A patient was admitted to the hospital and got three times their normal dose of phenytoin resulting in phenytoin toxicity and a long hospital stay. Analysis of the error revealed problems with hospital organization, supervision issues and having an environment that facilitates errors. Errors don’t occur simply because one clinician makes a mistake—rather they occur because the hospital system fails to prevent them.

Related article: Phenytoin Toxicity—A Significant Adverse Drug Event

Mar 28, 2017

A resident is asked to remove a drain that was placed in the lumbar space during an operation. Having never seen this sort of drain before not having removed one, the resident proceeded to remove the catheter. Several days later, the patient complained of persistent drainage. An 11-cm segment of retained catheter was removed. This JAMA Performance Improvement article discusses how to avoid this sort of problem as well as how to ensure that resident physicians have sufficient skills to perform procedures on their own. We talk with Drs Cynthia Barnhard, John DeLancey, authors of Retained Lumbar Catheter Tip, and Dr Aaron Reynolds and Dr David Baker.

Related article: Retained Lumbar Catheter Tip


Jan 17, 2017

Latex allergy is common and usually benign but at times can be life-threatening. What can clinicians do to minimize the risk of serious complications attributable to latex allergy? We interview Cynthia Barnard, PhD, MBA, MSJS, and Erin Slade-Smith, MSN, RN, CNOR, both from Northwestern Memorial Hospital in Chicago, Illinois, and David W. Baker, MD, MPH, FACP, from The Joint Commission, to shed light on this serious issue.

Article discussed in this episode: Management of a Patient With a Latex Allergy