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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

Quality and variability of patient directions in electronic prescriptions in the ambulatory care setting.

Yang Y, Ward-Charlerie S, Dhavle AA, Rupp MT, Green J. J Manag Care Spec Pharm. 2018 Jan 18; [Epub ahead of print].

Qualitative content analysis of coworkers' safety reports of unprofessional behavior by physicians and advanced practice professionals.

Martinez W, Pichert JW, Hickson GB, et al. J Patient Saf. 2018 Mar 15; [Epub ahead of print].

Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.

Pontefract SK, Hodson J, Slee A, et al. BMJ Qual Saf. 2018 Mar 23; [Epub ahead of print].

The risks to patient safety from health system expansions.

Haas S, Gawande A, Reynolds ME. JAMA. 2018 Apr 6; [Epub ahead of print].

Bedside computer vision—moving artificial intelligence from driver assistance to patient safety.

Yeung S, Downing NL, Fei-Fei L, Milstein A. N Engl J Med. 2018;378:1271-1273.


Guideline Summary: Medication Safety.

Association of PeriOperatve Registered Nurses. AORN J. 2018;107:489-494.


A Just Culture Guide.

NHS Improvement. London, UK: National Health Service; March 15, 2018.

Press Release/Announcement

National Prescription Drug Take Back Day.

Drug Enforcement Administration. April 28, 2018.


TeamSTEPPS Canada: Master Trainer.

TeamSTEPPS Canada, Canadian Patient Safety Institute. May 8–9, 2018; Health Quality Council of Alberta, Calgary, Alberta, CAN.

Latest WebM&M Issue

Expert analysis of medical errors.

When Patients and Providers Speak Different Languages

  • Spotlight Case

Leah S. Karliner, MD, MAS, April 2018

Although the electronic health record noted that a woman required a Spanish interpreter to communicate with providers, no in-person interpreter was booked in advance. A non–Spanish-speaking physician attempted to use the clinic's phone interpreter services to communicate with the patient, but poor reception prevented the interpreter and patient from hearing each other. The patient called her husband, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. Fortunately, the physician was able to determine that the patient required further cardiac testing before proceeding with a planned elective surgery.

Air on the Side of Caution

Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD, April 2018

A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.

Walking Patient, Missing Drain

Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD, April 2018

Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Harlan Krumholz, MD, SM

Post-Hospital Syndrome, April 2018

Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.


Patient Safety During Hospital Discharge

Post-Hospital Syndrome, April 2018

Katherine Liang and Eric Alper, MD

This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.

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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?

Types of miscommunication reported by parents and attending physicians.


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Upcoming & Noteworthy

Improving Patient Safety in Primary Care by Engaging Patients and Families—Four Strategies for Success.

IHI/NPSF Professional Learning Series Webcast. April 26, 2018; 12:00–1:00 PM (Eastern).

Driving Patient Safety and Quality Through Opioid Stewardship.

National Quality Forum. May 1, 2018; National Quality Forum, Washington, DC.

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Most Viewed


Prevalence and Economic Burden of Medication Errors in the NHS England.

Elliott RA, Camacho E, Campbell F, et al. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Sheffield, United Kingdom: University of Sheffield and University of York; 2018.


The natural history of recovery for the healthcare provider "second victim" after adverse patient events.

Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. Qual Saf Health Care. 2009;18:325-330.


Residents' response to duty-hour regulations—a follow-up national survey.

Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.