February 2013
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Perspectives on Safety
Engaging the Patient and Family in Safety
In Conversation With… Beverley H. Johnson
Beverley Johnson is President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care.
(.MP3 | 11.3 MB)
Patient Engagement and Patient Safety
by Saul N. Weingart, MD, PhD

This piece highlights the advantages to and limitations of engaging patients in patient safety.
Cases & Commentaries
After her discharge, providers were unable to reach a young woman hospitalized for heavy vaginal bleeding, whose chlamydia culture returned positive. The delay in treatment led to infection of her fallopian tubes and required hospitalization for intravenous antibiotics.
Commentary by David Shapiro, MD, JD
CME/CEU credit available for this case

After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Commentary by Rodney W. Hicks, PhD, RN, FNP

A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.
Commentary by Mark Ault, MD, and Bradley Rosen, MD, MBA
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