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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

Hospital-readmission risk—isolating hospital effects from patient effects.

Krumholz HM, Wang K, Lin Z, et al. N Engl J Med. 2017;377:1055-1064.

Medical malpractice lawsuits involving surgical residents.

Thiels CA, Choudhry AJ, Ray-Zack MD, et al. JAMA Surg. 2017 Aug 30; [Epub ahead of print].

The impact of checklists on inpatient safety outcomes: a systematic review of randomized controlled trials.

Boyd JM, Wu G, Stelfox HT. J Hosp Med. 2017;12:675-682.

Identifying patient and practice characteristics associated with patient-reported experiences of safety problems and harm: a cross-sectional study using a multilevel modelling approach.

Ricci-Cabello I, Reeves D, Bell BG, Valderas JM. BMJ Qual Saf. 2017 Aug 7; [Epub ahead of print].

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2016.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2017;74:1336-1352.

User-centered collaborative design and development of an inpatient safety dashboard.

Mlaver E, Schnipper JL, Boxer RB, et al. Jt Comm J Qual Patient Saf. 2017 Aug 14; Epub ahead of print].


Inadequate hand-off communication.

Sentinel Event Alert. September 11, 2017;(58):1-6.


Prescription Drug Monitoring Programs: Evolution and Evidence.

Weiner J, Bao Y, Meisel Z. LDI/CHERISH Issue Brief. June 2017.

Communicating Clearly About Medicines: Proceedings of a Workshop.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.

Newspaper/Magazine Article

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.

Latest WebM&M Issue

Expert analysis of medical errors.

Transfusion Thresholds in Gastrointestinal Bleeding

  • Spotlight Case

Lisa Strate, MD, MPH, and Sophia Swanson, MD, September 2017

An older man with Crohn disease was admitted for abdominal pain and high stool output from his ileostomy. Despite blood passing from his ostomy and a falling hemoglobin level, the patient was not given a timely blood transfusion.

The Forgotten Radiographic Read

Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD, September 2017

A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.

Failed Interpretation of Screening Tool: Delayed Treatment

Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc, September 2017

For an older patient presenting with upper back pain and faint bilateral crackles, physicians misinterpreted a negative sepsis screen as a negative infection screen and delayed antibiotic treatment for pneumonia. The patient developed worsened hypoxemia, hypotension, delirium, and progressive organ failure.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Andrew Gettinger, MD

Health Information Technology and Safety, September 2017

Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Clinical Quality and Safety for the Office of the National Coordinator (ONC). He led the development of an electronic health record (EHR) system at Dartmouth and was the senior physician leader during their transition to a vendor-based EHR. We spoke with him about safety and health information technology.


Assessing the Safety of Electronic Health Records: What Have We Learned?

Health Information Technology and Safety, September 2017

Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH

This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.

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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?

Clinician-provided reason for voiding medication orders.


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Upcoming & Noteworthy

John M. Eisenberg Patient Safety and Quality Award.

The Joint Commission and National Quality Forum.

2018 American Hospital Association–McKesson Quest for Quality Prize.

Chicago, IL: American Hospital Association and Health Research & Educational Trust.

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Most Viewed


'Clean Care is Safer Care': the Global Patient Safety Challenge 2005-2006.

Pittet D, Allegranzi B, Storr J, Donaldson L. Int J Infect Dis. 2006;10:419-24.


Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Arriaga AF, Gawande AA, Raemer DB, et al; Harvard Surgical Safety Collaborative. Ann Surg. 2014;259:403-410.