Welcome to the NEW PSNet!

Learn More

Try our redesigned website on your tablet or mobile device.

Journal Article

National cluster-randomized trial of duty-hour flexibility in surgical training.

Bilmoria KY, Chung JW, Hedges LV, et al. N Engl J Med. 2016 Feb 2; [Epub ahead of print].

Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.

Overdyk FJ, Dowling O, Newman S, et al. BMJ Qual Saf. 2015 Dec 11; [Epub ahead of print].

A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital.

Bock M, Doz P, Fanolla A, et al. JAMA Surg. 2016 Feb 3; [Epub ahead of print].

Tallman lettering as a strategy for differentiation in look-alike, sound-alike drug names: the role of familiarity in differentiating drug doppelgangers.

DeHenau C, Becker MW, Bello NM, Liu S, Bix L. Appl Ergon. 2016;52:77-84.

Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions.

Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Am J Surg. 2016;211:437-444.

Provider-to-provider communication during transitions of care from outpatient to acute care: a systematic review.

Luu NP, Pitts S, Petty B, et al. J Gen Intern Med. 2015 Dec 21; [Epub ahead of print].

Does physician's training induce overconfidence that hampers disclosing errors?

Brezis M, Orkin-Bedolach Y, Fink D, Kiderman A. J Patient Saf. 2016 Jan 11; [Epub ahead of print].

Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system.

Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. BMC Anesthesiol. 2016;16:4.

Book/Report

The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness.

Anderson-Fletcher E, Vera D, Abbott J. Houston, TX: Hobbs Center for Public Policy, University of Houston; 2015.

Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report.

Cambridge, MA: CRICO Strategies; 2016.

Patient Safety Risk Management Playbook.

Chicago, IL: American Society for Healthcare Risk Management; 2015.

Newspaper/Magazine Article

Drug shortages forcing hard decisions on rationing treatments.

Fink S. New York Times. January 29, 2016.

Soaring numbers of 111 callers forced to wait for a call back.

Donnelly L. The Telegraph. January 31, 2016.

Meeting/Conference

Evaluation of Perioperative Medication Errors and Adverse Drug Events.

National Patient Safety Foundation. February 25, 2016; 2:00–3:00 PM (Eastern).

5th Annual Oregon Patient Safety Forum.

Oregon Patient Safety Commission. February 26, 2016; DoubleTree, Portland, OR.

Also of Note

Sentinel Event Issues: How to Prevent Harm.

Joint Commission Resources Quality & Safety Network and Centers for Medicare and Medicaid Services. February 25, 2016; 2:00–3:00 PM (Eastern).

Preventing Overdiagnosis.

Agency for Health Quality and Assessment of Catalonia, Dartmouth Institute, British Medical Journal, Bond University, Centre for Evidence-Based Medicine, and Consumer Reports. September 20–22, 2016; Barcelona International Convention Centre, Barcelona, Spain.

WebM&M Cases

A Room Without Orders

  • Spotlight Case
  • CME/CEU

Commentary by Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN

Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.

Take CME Quiz

New Patient Mistakenly Checked in as Another

Commentary by Robert A. Green, MD, MPH, and Jason Adelman, MD, MS

Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.

Inadvertent Use of More Potent Acid Leads to Burn

Commentary by Howard I. Maibach, MD

An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.

View all WebM&M Cases

Perspectives on Safety

Update on Diagnostic Errors

Interview

In Conversation With… Mark L. Graber, MD

Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.

Perspective

Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice

Hardeep Singh, MD, MPH

This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.

View all Perspectives

WebM&M is now on PSNet

AHRQ has merged Patient Safety Network (PSNet) and WebM&M (Morbidity and Mortality Rounds on the Web) for a more streamlined experience. Learn more.

View WebM&M content

Sign in to customize your topics of interest.

Did You Know?

Most medication errors involving older patients occurred between 7–9 AM.

Source

Popular Content

Study

An evaluation of parenteral nutrition errors in an era of drug shortages.

Storey MA, Weber RJ, Besco K, Beatty S, Aizawa K, Mirtallo JM. Nutr Clin Pract. 2015 Oct 27; [Epub ahead of print].

WebM&M Cases

Overdose on Oxygen?

Commentary by B. Ronan O'Driscoll, MD

Study

Associations between attending physician workload, teaching effectiveness, and patient safety.

Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. J Hosp Med. 2016 Jan 6; [Epub ahead of print].

Study

Prevalence and characteristics of physicians prone to malpractice claims.

Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. N Engl J Med. 2016;374:354-362.

Regulation

National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2015.