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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 free CME 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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April 10, 2024 Weekly Issue

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

Sherbino J, Sibbald M, Norman GR, et al. BMJ Qual Saf. 2024;Epub Mar 19.
Collaboration between clinicians encourages better diagnostic decision making and clinical outcomes. This study sought to determine if collaboration improves diagnostic accuracy, assessing by collaborative group size (3 or 6 physicians) and process type (interactive or retrospective). Groups had better diagnostic accuracy than individuals, regardless of group size. Process types were equally effective. ...
Li L, Baker J, Quirk R, et al. Drug Saf. 2024;Epub Mar 13.
Drug-drug interactions (DDI) can be harmful. This study examined frequency of potential DDI (pDDI) and clinically relevant DDI (cDDI) in three hospitals both before and after implementation of an electronic medication management (EMM) system, without accompanying decision support alerts. The frequency of pDDI and cDDI orders did not differ between timeframes, although the likelihood of both drugs being...
Tang KM, Lee P, Anosike BI, et al. Hosp Pediatr. 2024;14:281-290.
Antimicrobial stewardship programs (ASPs) can reduce antimicrobial prescribing errors. In this quality improvement study, researchers implemented a standardized workflow intended to reduce prescribing errors among pediatric patients on ASP-restricted medication courses (e.g., vancomycin, levofloxacin). Workflow interventions included ASP education, a pharmacy standardized operating procedure, best...
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Training and Education

Update Date: April 10, 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 CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

Eric Signoff, MD, Noelle Boctor, MD, and David K. Barnes, MD, FACE | April 10, 2024

A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech,... Read More

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Improvement Resources

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


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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Create your own library to save and manage content on any topic of interest. You can start by searching for articles or by creating your library right here.