Welcome to PSNet

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

Journal Article

Association of overlapping surgery with increased risk for complications following hip surgery.

Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2017 Dec 4; [Epub ahead of print].

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.

Grant S, Guthrie B. BMJ Qual Saf. 2017 Nov 9; [Epub ahead of print].

Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.

Pattni N, Bould MD, Hayter MA, et al. Br J Anaesth. 2017;119:697-702.

Exploring how nursing schools handle student errors and near misses.

Disch J, Barnsteiner J, Connor S, Brogren F. Am J Nurs. 2017;117:24-31.

Twelve tips for embedding human factors and ergonomics principles in healthcare education.

Vosper H, Hignett S, Bowie P. Med Teach. 2017 Nov 10; [Epub ahead of print].

New solutions to reduce wrong route medication errors.

Litman RS, Smith VI, Mainland P. Paediatr Anaesth. 2017 Nov 17; [Epub ahead of print].

Diagnostic errors by medical students: results of a prospective qualitative study.

Braun LT, Zwaan L, Kiesewetter J, Fischer MR, Schmidmaier R. BMC Med Educ. 2017;17:191.


Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.

Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.

Latest WebM&M Issue

Expert analysis of medical errors.

Dying in the Hospital With Advanced Dementia

  • Spotlight Case

Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA, December 2017

Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.

Miscommunication in the OR Leads to Anticoagulation Mishap

Ian Solsky, MD, and Alex B. Haynes, MD, MPH, December 2017

Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding.

Over-the-Counter Oversight

Varalakshmi Janamanchi, MD; Kunjam Modha, MD; and Christopher Whinney, MD, December 2017

At a preoperative evaluation for skin grafting surgery, a man's prescription medications were reviewed and updated in his medical record. During surgery, the patient experienced profuse bleeding, requiring transfusion with multiple units of blood. Postoperatively, the patient stabilized and the attending surgeon reexamined the patient's medications with him and asked about over-the-counter medications. The patient had been taking one aspirin per day, including the day of surgery. Although the patient was asked about blood-thinning medications at the preoperative visit, he was not asked about over-the-counter medications.

View All Cases

Latest Perspectives

Expert viewpoints on current themes in patient safety.


Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.


The Evolution of Patient Safety in Surgery

Surgical Safety, December 2017

Robert M. Wachter, MD

This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.

View All Perspectives

Patient Safety Primers

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

View All Primers

Did You Know?

Factors associated with potentially preventable readmissions.


View All DYKs

Upcoming & Noteworthy

2018–2019 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; 2017.

CUSP Implementation Workshop.

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

View Upcoming Events

Most Viewed


Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.


Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process.

Bonnabry P, Cingria L, Ackermann M, Sadeghipour F, Bigler L, Mach N. Int J Qual Health Care. 2006;18:9-16.


'Clean Care is Safer Care': the Global Patient Safety Challenge 2005-2006.

Pittet D, Allegranzi B, Storr J, Donaldson L. Int J Infect Dis. 2006;10:419-24.