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Cases & Commentaries: SEPTEMBER 2008

Nursing

Medicine

Medicine

	Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care SPOTLIGHT CASE Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.
	Commentary by Victoria Rich, PhD, RN
	CME/CEU available

	Hiding in Plain Sight One day after being discharged from the ED, a woman with severe back pain returns and is admitted for observation and analgesics. The next morning, the hospitalist notes a vesicular rash in the exact distribution of the patient's pain symptoms and diagnoses a herpes zoster infection (shingles).
	Commentary by Jeffrey M. Weinberg, MD

	Is the Admission Drug Dose Too Low? The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
	Commentary by Rainu Kaushal, MD, MPH; Erika Abramson, MD


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Perspectives on Safety

	This month: Workarounds

	•	In Conversation with... Steven J. Spear, DBA, MS, MS Listen to podcast (.MP3 \| 3.8 MB \| 8:03)

	•	Workarounds and Resiliency on the Front Lines of Health Care Anita L. Tucker, DBA, MS

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Patient Safety Network

What's New: Involving patients in medication reconciliation makes the process more effective.

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Did You Know?

Of 3522 patients surveyed, 4.2% reported experiencing a harmful adverse event in the past year.

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