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Patient Safety Network

Promoting Patient Safety.

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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for CE without a fee and trainings. The platform provides powerful searching and browsing capability, as well as the ability for users to customize the site around their interests (My Profile).

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December 4, 2024 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.

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Study
How many is too many? Using cognitive load theory to determine the maximum safe number of inpatient consultations for trainees.
Brondfield S, Blum AM, Mason JM, et al. Acad Med. 2024;99:1260-1266.
Interruptions and distractions increase cognitive load, raising the risk of errors. In this study, internal medicine and psychiatry residents and fellows responded to four questions designed to assess their cognitive load during and after inpatient consultations. After four consultations in one shift, trainees agreed or strongly agreed that interruptions, emotions, extraneous information, and technology...
Study
"It is not the fault of the health care team - it is the way the system works": a mixed-methods quality improvement study of patients with advanced cancer and family members reveals challenges navigating a fragmented healthcare system and the administrative and financial burdens of care.
Dillon EC, Martinez MC, Li M, et al. BMC Health Serv Res. 2024;24:1378.
Patients with complex care needs often face financial or logistical barriers when receiving care. In this study, patients with advanced cancer and their caregivers reported lower quality of care, lower quality of life, and worse trust in the healthcare system. Participants were generally positive about healthcare interactions but detailed insurmountable barriers, such as cost and navigating "invisible"...
Study
Safety of inpatient care in surgical settings: cohort study.
Duclos A, Frits ML, Iannaccone C, et al. BMJ. 2024;387:e080480.
Despite decades of safety improvement efforts, surgical complications continue to occur. In this multicenter retrospective study of 1,009 surgical patients, 38% experienced an adverse event and 15.9% experienced a major adverse event. Nearly 60% of adverse events were deemed potentially preventable. Adverse events involved all types of healthcare professionals and all areas of perioperative care (e.g.,...

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Training and Education

Update Date: October 30, 2024

WebM&M Case Studies & Spotlight Cases

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CE. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

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A Tale of Two Falls
Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN | October 30, 2024

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... Read More

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2024 IHI Forum

Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.

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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

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Toolkits

Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.

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