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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

Prevention of prescription opioid misuse and projected overdose deaths in the United States.

Chen Q, Larochelle MR, Weaver DT, et al. JAMA Netw Open. 2019;2:e187621.

Avoiding chemotherapy prescribing errors: analysis and innovative strategies.

Reinhardt H, Otte P, Eggleton AG, et al. Cancer. 2019 Jan 29; [Epub ahead of print].

A decade of health information technology usability challenges and the path forward.

Ratwani RM, Reider J, Singh H. JAMA. 2019 Feb 4; [Epub ahead of print].

Harveian Oration 2018: improving quality and safety in healthcare.

Dixon-Woods M. Clin Med (Lond). 2019;19:47-56.

The effect of a clinical decision support for pending laboratory results at emergency department discharge.

Driver BE, Scharber SK, Fagerstrom ET, Klein LR, Cole JB, Dhaliwal RS. J Emerg Med. 2019;56:109-113.

Using computerized virtual cases to explore diagnostic error in practicing physicians.

Trowbridge RL, Reilly JB, Clauser JC, Durning SJ. Diagnosis (Berl). 2018;5:229-233.

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.

Horn SR, Liu TC, Horowitz JA, et al. Spine (Phila Pa 1976). 2018;43:E1358-E1363.

Association of emotional intelligence with malpractice claims: a review.

Shouhed D, Beni C, Manguso N, IsHak WW, Gewertz BL. JAMA Surg. 2019 Jan 30; [Epub ahead of print].

Newspaper/Magazine Article

When is the surgeon too old to operate?

Span P. New York Times. February 1, 2019.

Press Release/Announcement

Notice of Intent to Publish Funding Opportunity Announcement to Improve Care Transitions Through the Use of Interoperable Health Information Technology (R01).

Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.


Improving Diagnosis Through Research into the Physician's Mind and the Patient's Experience.

Washington Patient Safety Coalition. WPSC Lunchtime Webinar Series. February 21, 2019, 2:00 PM (Eastern).

Latest WebM&M Issue

Expert analysis of medical errors.

Triaging Interhospital Transfers

  • Spotlight Case
  • CE/MOC

Stephanie Mueller, MD, MPH, February 2019

To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.

Adverse Event During Intrahospital Transport

Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD, February 2019

Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.

Diagnostic Failure: The Growing Deficit

Robert Chang, MD, and Scott Flanders, MD, February 2019

A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Susan E. Skochelak, MD, PhD

Teaching Patient Safety, February 2019

Dr. Skochelak is the Group Vice President for Medical Education at the American Medical Association (AMA). She leads the AMA's Accelerating Change in Medical Education initiative, which aims to align physician training with the changing needs of our health care system. We spoke with her about her experience in medical education.


Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc

This piece spotlights the need for educational and cultural transformation to achieve sustainable progress in patient outcomes and health.

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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?

Handoff communication before and after I-PASS implementation in nursing.


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Upcoming & Noteworthy

Front Line of Defense: The Role of Nurses in Preventing Sentinel Events. Third Edition.

Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.

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Most Viewed


Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research.

Miller A, Moon B, Anders S, Walden R, Brown S, Montella D. Int J Med Inform. 2015;84:1009-1018.

Newspaper/Magazine Article

Pharmacists play key role in patient safety.

DukeMed News [serial online]. January 8, 2005.


Why patient safety is such a tough nut to crack.

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