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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

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.

van der Veen W, van den Bemt PMLA, Wouters H, et al; BCMA Study Group. J Am Med Inform Assoc. 2018;25:385-392.

The first U.S. study on nurses' evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes.

Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. Worldviews Evid Based Nurs. 2018;15:16-25.

Time out—charting a path for improving performance measurement.

MacLean CH, Kerr EA, Qaseem A. N Engl J Med. 2018 Apr 18; [Epub ahead of print].

A target to achieve zero preventable trauma deaths through quality improvement.

Hashmi ZG, Haut ER, Efron DT, Salim A, Cornwell EE III, Haider AH. JAMA Surg. 2018 Apr 11; [Epub ahead of print].

Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system.

Chung C, Patel S, Lee R, et al. Am J Health Syst Pharm. 2018;75:398-406.

Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care.

Vaughn VM, Linder JA. BMJ Qual Saf. 2018 Mar 24; [Epub ahead of print].

Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis.

Mimmo L, Harrison R, Hinchcliff R. BMJ Paediatr Open. 2018;2:e000201.


Physical and verbal violence against health care workers.

Sentinel Event Alert. April 16, 2018;(59):1-9.

Special or Theme Issue

Opioid Stewardship.

Ochsner J. 2018;18:20-45.


Injectable Opioid Shortages: Suggestions for Management and Conservation.

Bethesda MD: American Society of Health-System Pharmacists and the University of Utah Drug Information Service; 2018.


Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18).

Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750.

Latest WebM&M Issue

Expert analysis of medical errors.

When Patients and Providers Speak Different Languages

  • Spotlight Case

Leah S. Karliner, MD, MAS, April 2018

Although the electronic health record noted that a woman required a Spanish interpreter to communicate with providers, no in-person interpreter was booked in advance. A non–Spanish-speaking physician attempted to use the clinic's phone interpreter services to communicate with the patient, but poor reception prevented the interpreter and patient from hearing each other. The patient called her husband, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. Fortunately, the physician was able to determine that the patient required further cardiac testing before proceeding with a planned elective surgery.

Air on the Side of Caution

Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD, April 2018

A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.

Walking Patient, Missing Drain

Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD, April 2018

Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Harlan Krumholz, MD, SM

Post-Hospital Syndrome, April 2018

Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.


Patient Safety During Hospital Discharge

Post-Hospital Syndrome, April 2018

Katherine Liang and Eric Alper, MD

This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.

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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

Annual International Forum on Quality and Safety in Healthcare.

Institute for Healthcare Improvement, British Medical Journal. May 2–4, 2018; Amsterdam RAI Exhibition and Convention Centre, Amsterdam, The Netherlands.

10th International Pediatric Simulation Symposia and Workshops.

International Pediatric Simulation Society. May 14–16, 2018; Sheraton Amsterdam Airport Hotel and Conference Center, Amsterdam, The Netherlands.

View Upcoming Events

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.


Sponges, tools and more left inside Washington hospital patients.

Ryan J. KUOW. National Public Radio. August 1, 2013.


Exploring approaches to patient safety: the case of spinal manipulation therapy.

Rozmovits L, Mior S, Boon H. BMC Complement Altern Med. 2016;16:164.