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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.

Study
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
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
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.

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

Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

Upcoming Events

United States Meeting/Conference

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

Improvement Resources
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Innovations

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

Toolkit
Toolkits

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

Create Your Own Library

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.