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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 free CME 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 13, 2024 Weekly Issue

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

Commentary
Hooven K, Altmiller G. AORN J. 2024;119:152-160.
Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" program, and leadership support for staff who submit...
Study
Holmes L, Enwere M, Mason R, et al. Healthcare (Basel). 2024;12:477.
Structural racism in the healthcare system and beyond contributes to disproportionally high mortality for Black children. In this study, researchers compared mortality rates of Black and white infants using the International Classification of Diseases (ICD) subclass Misadventures to Patients During Surgical and Medical Care, where the authors defined misadventures as "the fatal medical errors that occur...
Study
Marcin JP, Lieng MK, Mouzoon J, et al. JAMA Netw Open. 2024;7:e240275.
Medication errors among children remain a patient safety challenge. This cluster randomized trial evaluated medication errors among critically ill children presenting to the Emergency Department (ED) and randomized to receive either video telemedicine or telephone consultations with pediatric critical care physicians. A physician-related medication error occurred in 12.5% of participants overall, with no...
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Training and Education

Update Date: February 28, 2024

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 CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

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.

Upcoming Events

Improvement Resources
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Innovations

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

Toolkit
Toolkits

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

Create Your Own Library

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.