Primary cutaneous adenoid cystic carcinoma (ACC) is a rare skin tumor that is unlikely to metastasize. We present a case of primary cutaneous ACC in a 67-year-old male with axillary lymph node, pulmonary and brain metastases. To the best of our knowledge, this is the first reported case of cutaneous ACC with distant metastases to the brain.

Building high reliable healthcare systems to reduce avoidable patient harm is a global priority. However, there is variability in the application and understanding of the previously identified High Reliability Organization (HRO) principles to make improvements. We describe specific organizational activities exemplifying the five HRO principles during the planning and go-live periods of the new Electronic Health Record (EHR) system at a multi-site academic health sciences centre in Ontario, Canada. Further, we describe a case example where all five HRO principles were exemplified during EHR implementation. Overall, 23 activities exemplifying organizational anticipation and resiliency were identified. Of the 23 activities, 12 occurred during the preparing for go-live and 11 activities occurred during the go-live periods. This paper demonstrates how HRO principles can be used in healthcare to detect and adapt to patient safety threats, in order to prevent avoidable patient harm during large scale change.

Introduction Escalation of care is the timely recognition and communication of deterioration in a previously stable patient. Delays in escalating care may lead to unnecessary patient morbidity and mortality. There is currently a paucity of synthesis of work focused on the initiation of escalation of care in the emergency department (ED), where unique challenges may be present. We sought to complete a scoping review to investigate: (1) factors (barriers and/or facilitators) affecting clinicians in escalating care in the ED; and (2) tools that support clinicians in ED escalation of care processes. Methods We conducted a scoping review guided by the Arksey & O'Malley framework, and in accordance with PRISMA Scoping Reviews (PRISMA-ScR) checklist. Searches were conducted in MEDLINE, EMBASE and CINAHL on November 30th, 2020. Extracted data was analyzed via qualitative content analysis. Review and data abstraction were completed by two independent reviewers. Discrepancies were resolved via consensus meetings with a third reviewer. Results Of the 4527 unique records identified, 13 studies met our inclusion criteria. Studies described standard escalation practices including detection, reporting, and response. Factors influencing escalation of care were described on individual (confidence, comfort, and expertise), interpersonal (communication and the nurse-physician relationship), organizational (workload and staffing), and environmental (distractions and layout) levels. Four ED-specific tools for escalation of care were also identified. Conclusion This scoping review identified 13 studies that contained information on processes, factors influencing and/or tools used to facilitate escalation of care in the ED. They may serve as valuable starting points for ED clinicians and administrators who are building or reforming local escalation of care processes.