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AHRQ: Agency for Healthcare Research and Quality
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This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Training Opportunities or Toolkits and are not providing technical support for the website.

Promoting Patient Safety.

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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for CE without a fee and trainings. The platform provides powerful searching and browsing capability, as well as the ability for users to customize the site around their interests (My Profile).

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March 12, 2025 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.

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Study
Medical large language models are vulnerable to data-poisoning attacks.
Alber DA, Yang Z, Alyakin A, et al. Nat Med. 2025;31:618-626.
To produce safe, accurate output, large language models (LLMs) must be trained on accurate information. In this study, researchers simulated a data-poisoning attack by implanting false medical information into a popular LLM training dataset. Results show that even a small amount of medical misinformation in the training dataset can result in harmful models that could compromise patient safety.
Commentary
A framework for the analysis of communication errors in health care.
Bender JA, Thiyagarajan S, Morrish W, et al. J Patient Saf. 2025;21:69-81.
Miscommunication is a major contributor to adverse events. This article describes the development of a framework to classify communication errors that contributed to a patient safety incident. Nine types of communication errors were identified. Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication errors.
Review
Adverse events involving telehealth in the Veterans Health Administration.
Mills PD, Tomolo A, Yackel EE. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20.
Health care is increasingly being provided remotely through telephone, video calls, and remote monitoring. Information on the prevalence and characterization of adverse events associated with telehealth is paramount to improving safety. This study analyzed 145 safety incidents related to telehealth at the VHA. The largest category was delays in care, and 90% of incidents resulted in no harm. Just over...

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Training and Education

Update Date: March 25, 2025

WebM&M Case Studies & Spotlight Cases

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CE. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

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Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.
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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

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Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.

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Create your own library to save and manage content on any topic of interest. You can start by searching for articles or by creating your library right here.
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