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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

Potential consequences of patient complications for surgeon well-being: a systematic review.

Srinivasa S, Gurney J, Koea J. JAMA Surg. 2019 Mar 27; [Epub ahead of print].

Using incident reports to assess communication failures and patient outcomes.

Umberfield E, Ghaferi AA, Krein SL, Manojlovich M. Jt Comm J Qual Patient Saf. 2019 Mar 29; [Epub ahead of print].

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety.

Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2019 Mar 13; [Epub ahead of print].

Improving employee voice about transgressive or disruptive behavior: a case study.

Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.

Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital.

Dalal AK, Fuller T, Garabedian P, et al. J Am Med Inform Assoc. 2019 Mar 22; [Epub ahead of print].

Saving without compromising: teaching trainees to safely provide high value care.

Judson TJ, Press MJ, Detsky AS. Healthc (Amst.). 2019;7:4-6.

Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship.

Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4:e001220.

Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers.

Coughlin JM, Shallcross ML, Schäfer WLA, et al. J Surg Res. 2019;239:309-319.


Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative Database Report.

Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.

Newspaper/Magazine Article

When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?

Gordon M. Health Shots. National Public Radio. April 10, 2019.


Caring for the Caregiver: The RISE Program.

Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Maryland Patient Safety Center. May 30, 2019; Armstrong Institute for Patient Safety and Quality, Baltimore, MD.

Latest WebM&M Issue

Expert analysis of medical errors.

What Happened on Telemetry?

  • Spotlight Case
  • CE/MOC

by Kristin E. Sandau, PhD, RN, and Marjorie Funk, PhD, RN, April 2019

An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died. Although the telemetry technician had recognized progressive bradycardia and called the hospital floor several minutes before the code, he was placed on hold because the nurse was busy with another patient. While he was holding, he observed worsening bradycardia, eventually transitioning to asystole, and tried to redial the unit, but no one answered.

E-cigarette Explosion in a Patient Room

Neal L. Benowitz, MD, April 2019

A woman who required oxygen at home via nasal cannula and used a continuous positive airway pressure (CPAP) machine at night was admitted for an exacerbation of chronic obstructive pulmonary disease without any signs of infection. During her hospital stay, she continued to require 5 liters of oxygen by nasal cannula. Although the patient had received smoking cessation education and no longer smoked regular cigarettes, she did continue to vape with an electronic cigarette (e-cigarette). Having not been told to avoid vaping in the hospital, the patient took a puff on her e-cigarette while she was receiving oxygen through her nasal cannula and sparked an explosion. She ripped off the nasal cannula, which had melted, and sustained burns to her face and hand, resulting in a prolonged hospitalization for burn care and extensive pain management.

Hip Fractures in Older Patients: the Case for Geriatrics Comanagement

Stephanie Rogers, MD, and Derek Ward, MD, April 2019

An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Timothy B. McDonald, MD, JD

New Insights Into Apology and Disclosure Programs, April 2019

Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.


In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD

New Insights Into Apology and Disclosure Programs, April 2019

Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.

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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?

Care processes affected by electronic health record downtime.


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Upcoming & Noteworthy

2019 Northwest Patient Safety Conference.

Washington Patient Safety Coalition. May 7, 2019; Hilton Seattle Airport & Conference Center, Seattle, WA.

Communication, Apology, and Resolution Forum.

Massachusetts Alliance for Communication and Resolution Following Medical Injury. May 7, 2019; Massachusetts Medical Society, Waltham, MA.

ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.

Horsham, PA: Institute for Safe Medication Practices; 2018.

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Most Viewed


Why patient safety is such a tough nut to crack.

Leistikow IP, Kalkman CJ, Bruijn H. BMJ. 2011;342:d3447.


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

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

Newspaper/Magazine Article

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.