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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

The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities.

Schwartz ME, Welsh DE, Paull DE, et al. J Healthc Risk Manag. 2017 Nov 9; [Epub ahead of print].

Are parents who feel the need to watch over their children's care better patient safety partners?

Cox ED, Hansen K, Rajamanickam VP, et al. Hosp Pediatr. 2017 Nov 15; [Epub ahead of print].

Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.

Boockvar KS, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.

Measuring patient safety in real time: an essential method for effectively improving the safety of care.

Classen DC, Griffin FA, Berwick DM. Ann Intern Med. 2017 Nov 21; [Epub ahead of print].

Interventions for the reduction of prescribed opioid use in chronic non-cancer pain.

Eccleston C, Fisher E, Thomas KH, et al. Cochrane Database Syst Rev. 2017;11:CD010323.

Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.

Sarkar U, McDonald K, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission.

Santana MJ, Holroyd-Leduc J, Southern DA, et al; e-DCT Team. BMJ Qual Saf. 2017;26:993-1003.


Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.

Special or Theme Issue

Focus On: Health Care Policy and Quality.

AJR Am J Roentgenol. 2017;209:965-1008;W333-W334.

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.

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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.

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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?

Clinicians' recommended solutions for delayed diagnosis in primary care.


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Upcoming & Noteworthy

IHI National Forum on Quality Improvement in Health Care.

Institute for Healthcare Improvement. December 10–13, 2017; World Center Marriott, Orlando, FL. 

Anesthesia Patient Safety Foundation (APSF) Grant Program.

Indianapolis, IN: Anesthesia Patient Safety Foundation.

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Most Viewed


Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.


Continuous improvement as an ideal in health care.

Berwick DM. N Engl J Med. 1989;320:53-56.


Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.