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PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more.

Journal Article

Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery.

Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319:143-153.

The hidden cost of regulation: the administrative cost of reporting serious reportable events.

Blanchfield BB, Acharya B, Mort E. Jt Comm J Qual Patient Saf. 2018 Jan 3; [Epub ahead of print].

What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation.

Liberati EG, Ruggiero F, Galuppo L, et al. Implement Sci. 2017;12:113.

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial.

Mohan D, Farris C, Fischhoff B, et al. BMJ. 2017;359:j5416.

Association of hospitalist years of experience with mortality in the hospitalized Medicare population.

Goodwin JS, Salameh H, Zhou J, Singh S, Kuo YF, Nattinger AB. JAMA Intern Med. 2017 Dec 26; [Epub ahead of print].

Insulin dosing error in a patient with severe hyperkalemia.

Hewitt DB, Barnard C, Bilimoria KY. JAMA. 2017;318:2485-2486.

What this computer needs is a physician: humanism and artificial intelligence.

Verghese A, Shah NH, Harrington RA. JAMA. 2018;319:19-20.

Association between organisational and workplace cultures, and patient outcomes: systematic review.

Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G. BMJ Open. 2017;7:e017708.


Toolkit to Promote Safe Surgery.

Rockville, MD: Agency for Healthcare Research and Quality; November 2017.


Improving Patient Care Through Safe Health IT.

Philadelphia, PA: Pew Charitable Trusts; December 2017.

Latest WebM&M Issue

Expert analysis of medical errors.

A Painful Medication Reconciliation Mishap

  • Spotlight Case

Roger Chou, MD, January 2018

A woman who had been taking naltrexone to treat alcohol use disorder was discharged to a skilled nursing facility (SNF) on opioids for pain following spinal fusion surgery. Although her naltrexone was held at the hospital in anticipation of starting opioids for pain control, the clinician performing medication reconciliation at the SNF overrode the drug–drug interaction alert and restarted the naltrexone. The SNF providers did not realize that the naltrexone blocked the pain-relieving effect of the opioids.

Slow Down: Right Drug, Wrong Formulation

Mary G. Amato, PharmD, MPH, and Gordon D. Schiff, MD, January 2018

Admitted for intravenous diuretic therapy and control of his atrial fibrillation, an older man was mistakenly given metoprolol tartrate instead of his home dose of extended-release metoprolol succinate. That night, he developed atrioventricular block, experienced a pulseless electrical activity cardiac arrest, and died. Review of the case identified problems in the human factors design in the computerized order entry system that contributed to the prescribing error.

A Costly Colonoscopy Leads to a Delay in Diagnosis

Christopher Moriates, MD, January 2018

Following a positive fecal immunochemical test (a screening test for colon cancer), a colonoscopy was ordered for a 50-year-old man. Two months later, the nurse called him to see if he had obtained the colonoscopy. The patient reported that he was unable to schedule it due to cost of the copayment. The primary physician called the insurance company and was informed that the colonoscopy would be covered in full if the indication was written as preventive rather than diagnostic. Ultimately, the patient received the colonoscopy and was diagnosed with colon cancer 6 months after his initial positive screening test.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Robert Hirschtick, MD

Clinical Documentation in the Modern Era, January 2018

Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a number of prominent articles—many quite amusing—about the changes in medical practice wrought by information technology. We spoke with him about what it means to be a clinician in the modern era, particularly how digitization of health records has affected clinicians' notes.


EHR Copy and Paste and Patient Safety

Clinical Documentation in the Modern Era, January 2018

Shannon M. Dean, MD

This piece explores concerns regarding the use of copy and paste in electronic health records and offers potential strategies to improve clinical documentation accuracy.

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Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

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Did You Know?

Clinician-identified problems leading to delayed diagnosis in primary care.


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Upcoming & Noteworthy

CUSP Implementation Workshop.

Armstrong Institute for Patient Safety and Quality. January 23, 2018; Constellation Energy Building Conference Center, Baltimore, MD.

1st Annual Africa Forum on Quality and Safety in Healthcare.

Institute for Healthcare Improvement. February 19–21, 2018; South Africa Durban International Convention Center, Durban, South Africa.

National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2018.

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Most Viewed


Laboratory safety monitoring of chronic medications in ambulatory care settings.

Hurley JS, Roberts M, Solberg LI, et al. J Gen Intern Med. 2005;20:331-333. 


Sponges, tools and more left inside Washington hospital patients.

Ryan J. KUOW. National Public Radio. August 1, 2013.


Why patient safety is such a tough nut to crack.

Leistikow IP, Kalkman CJ, Bruijn H. BMJ. 2011;342:d3447.