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Patient Safety Network

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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October 9, 2024 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
Diagnostic discordance, uncertainty, and treatment ambiguity in community-acquired pneumonia: a national cohort study of 115 U.S. Veterans Affairs hospitals.
Jones BE, Chapman AB, Ying J, et al. Ann Intern Med. 2024;177:1179-1189.
An accurate diagnosis of pneumonia ensures that appropriate treatment can be administered in a timely manner. In this large retrospective study, researchers compared hospital admission and discharge diagnosis of community-acquired pneumonia. More than half of patients had a discordant diagnosis at discharge. EHR notes described more uncertainty for patients with discordance. This study highlights the...
Study
Defects in value associated with hospital-acquired conditions: how improving quality could save U.S. healthcare $50 billion.
Padula WV, Pronovost PJ. J Patient Saf. 2024;20:512-515.
Despite considerable health system efforts and governmental financial penalties, hospital-acquired conditions (HAC) continue to be a source of patient harm and organizational cost. Instead of the current model of financial penalties and non-payment for low-performing hospitals, the authors recommend rewarding high-performing hospitals and development of centers of excellence. They suggest the investment...
Commentary
Dual process models of clinical reasoning: the central role of knowledge in diagnostic expertise.
Norman G, Pelaccia T, Wyer P, et al. J Eval Clin Pract. 2024;30:788-796.
Diagnostic reasoning is frequently discussed in terms of System 1 (thinking fast) and System 2 (thinking slow). The authors of this review present evidence against the claim that diagnostic error stems solely from System 1 thinking. They conclude that errors originate from both System 1 and System 2 thinking. Errors typically occur due to lack of access to the appropriate knowledge, and neither system is...

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Training and Education

Update Date: September 25, 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.

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Hypoxic Gas Supply from Cross-Connected Pipelines
Christian Bohringer, MBBS, Adam Guemidjian, and Garth Utter, MD, MSc | September 25, 2024

An 8-year-old boy undergoing a neck mass aspiration experienced a sudden drop in oxygen saturation and heart rate, requiring CPR and intubation, due to... Read More

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2024 IHI Forum

Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.

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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

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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