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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

Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events.

Olson APJ, Graber ML, Singh H. J Gen Intern Med. 2018 Jan 29; [Epub ahead of print].

Implementation of diagnostic pauses in the ambulatory setting.

Huang GC, Kriegel G, Wheaton C, et al. BMJ Qual Saf. 2018 Jan 6; [Epub ahead of print].

Systems thinking and incivility in nursing practice: an integrative review.

Phillips JM, Stalter AM, Winegardner S, Wiggs C, Jauch A. Nurs Forum. 2018 Jan 23; [Epub ahead of print].

Technological distractions—part 1 and part 2.

Kane-Gill SL, O'Connor MF, Rothschild JM, et al; Society for Critical Care Medicine Alarm and Alert Fatigue Task Force. Crit Care Med. 2017;45:1481-1488, 2018;46:130-137.

Attending physician remote access of the electronic health record and implications for resident supervision: a mixed methods study.

Martin SK, Tulla K, Meltzer DO, Arora VM, Farnan JM. J Grad Med Educ. 2017;9:706-713.

IDEA4PS: the development of a research-oriented learning healthcare system.

Moffatt-Bruce S, Huerta T, Gaughan A, McAlearney AS. Am J Med Qual. 2018 Jan 1; [Epub ahead of print].

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.

Archer S, Hull L, Soukup T, et al. BMJ Open. 2017;7:e017155.

Promising roles for pharmacists in addressing the U.S. opioid crisis.

Compton WM, Jones CM, Stein JB, Wargo EM. Res Social Adm Pharm. 2017 Dec 31; [Epub ahead of print].


Pennsylvania Patient Safety Summit (P2S2).

Patient Safety Authority. April 5, 2018; The Penn Stater Conference Center and Hotel, State College, PA.

Latest WebM&M Issue

Expert analysis of medical errors.

Signout Fallout

  • Spotlight Case

Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH , February 2018

Admitted with an intracranial mass and hemorrhage, a woman with atrial fibrillation had been stable for several days when the ICU team and neurosurgeon decided that the benefits of low-dose DVT prophylaxis would outweigh the risk of serious bleeding. However, no dose or route of administration was specified, and the overnight resident ordered full-dose (rather than the prophylactic dose) anticoagulation. The hemorrhage grew and brain compression worsened, leaving the patient with no chance for meaningful recovery.

Returning Home Safely

Mark Toles, PhD, RN, February 2018

Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications.

Right Place, Right Drug, Wrong Strength

Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc, February 2018

A hospitalized pediatric burn patient underwent dressing changes and burn inspection every third day. On those days she received oxycodone for pain, which allowed her to tolerate the painful procedures and to rest. After a dressing change one day, the mother noticed the child's breathing was shallow. That day the patient had received three doses of oxycodone, but because the automated dispensing machine had been stocked incorrectly with a higher concentration of oxycodone solution stored in the location normally reserved for the lower concention, she received nearly five times the dose ordered.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Annual Perspective

Sumant Ranji, MD, 2017

A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.

Annual Perspective

Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017

Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.

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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?

Clinical effects of medication errors occurring in the community.


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Upcoming & Noteworthy

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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.

Newspaper/Magazine Article

Revealing their medical errors: why three doctors went public.

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

Newspaper/Magazine Article

Heed this warning! Don't miss important computer alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2.