C3.2 R4: Recognize and submit a Patient Safety Learning System Report (2/2)

I identified, reported, and followed-up on a patient safety event. The patient was a 59 year old complex female admitted with bacterial pneumonia and subsequently found to have a PE. She had multiple drug allergies, including an allergy of unknown reaction or severity to norfloxacin. Over the weekend, the patient was stepped down from IV … Continue reading C3.2 R4: Recognize and submit a Patient Safety Learning System Report (2/2)

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C3.2 R4: Recognize and submit a Patient Safety Learning System Report (1/2)

I completed a PSLS submission and discussed the incident and principles of risk evaluation management, root-cause analysis, and the incident disclosure, response, and outcome with the report handler. Without disclosing too much, the error occurred in an unstable patient on a surgery floor in atrial fibrillation with rapid ventricular response. Over the course of a … Continue reading C3.2 R4: Recognize and submit a Patient Safety Learning System Report (1/2)