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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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May 22, 2024 Weekly Issue

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

Estrada LV, Barcelona V, Dhingra L, et al. JAMA Netw Open. 2024;7:e249312.
Systemic racism and discrimination negatively impact the health of historically marginalized people. In this cross-sectional study of nursing home (NH) residents with severe cognitive impairment, historically marginalized residents had greater incidence of potentially avoidable hospitalizations compared to their white counterparts. Not only did the study identify racial and ethnic disparities at the...
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. BMJ Qual Saf. 2024;Epub Feb 16.
Anchoring bias occurs when a physician relies on their initial diagnostic impression despite subsequent information to the contrary. This study assessed the influence of disease knowledge on susceptibility to anchoring bias. In simulated case studies, physicians with higher disease knowledge were less likely than lower knowledge physicians to be biased by salient distracting features (e.g., patient...
Valkonen V, Saano S, Haatainen K, et al. J Patient Saf. 2024;Epub Apr 5.
Voluntary incident reporting data can provide unique insights into errors and opportunities to improve patient safety. This study used an enhanced free-text search method to identify the medication error (ME) reports involving substances commonly involved in medication errors (e.g., oxycodone, Warfarin). This approach increased the number of identified ME reports involving the specified medications and...
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Training and Education

Update Date: April 10, 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.

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Improvement Resources

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


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.