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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

Medication-related clinical decision support alert overrides in inpatients.

Nanji KC, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2017 Oct 27; [Epub ahead of print].

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.

Bradley EH, Brewster AL, McNatt Z, et al. BMJ Qual Saf. 2017 Nov 3; [Epub ahead of print].

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

Berger ZD, Brito JP, Ospina NS, et al. BMJ. 2017;359:j4218.

The effectiveness of assertiveness communication training programs for healthcare professionals and students: a systematic review.

Omura M, Maguire J, Levett-Jones T, Stone TE. Int J Nurs Stud. 2017;76:120-128.

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

Forster AJ, Bernard B, Drösler SE, et al. Int J Qual Health Care. 2017;29:548-556.


Patient Safety in the Office-Based Practice Setting.

Philadelphia, PA: American College of Physicians; 2017.

Special or Theme Issue

Quality Improvement.

Gupta M, Kaplan HC, eds. Clin Perinatol. 2017;44:469-728.


Medical misdiagnosis: more common than you think.

Kast S. "On the Record." WYPR. October 31, 2017.


1st Annual Africa Forum on Quality and Safety in Healthcare.

Institute for Healthcare Improvement. February 19–21, 2018; South Africa Durban International Convention Center, Durban, South Africa.

Latest WebM&M Issue

Expert analysis of medical errors.

Palliative Care: Comfort vs. Harm

  • Spotlight Case

Ralf Jox, MD, PhD, November 2017

An older man admitted for the third time in 4 weeks for an exacerbation of congestive heart failure expressed his wishes to focus on comfort and pursue hospice care. Comfort measures were initiated and other treatments were stopped. The care team wrote for a standing dose of IV hydromorphone every 4 hours. The night shift nurse administered the scheduled dose at 3:00 AM. At 7:00 AM, the palliative care attending found the patient obtunded, with shallow respirations and a low respiratory rate.

Delayed Diagnosis of Endocrinologic Emergencies

Cristiane Gomes-Lima, MD, and Kenneth D. Burman, MD, November 2017

Two cases in which thyroid function tests were ordered appropriately but not acted upon in a timely fashion illustrate the challenges of thyroid emergencies. The patient in Case #1 had a history of hyperthyroidism and noted not taking his medications for months, yet no one addressed his abnormal thyroid function tests until hospital day 3. He had thyroid storm. In Case #2, providers neglected to follow up on the patient's abnormal thyroid function tests, even though she was taking a medication with a known risk of thyroid toxicity. She had myxedema coma.

Specimen Almost Lost

Yael K. Heher, MD, MPH, November 2017

A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Wanda Pratt, PhD

Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017

Wanda Pratt is a professor in the Information School and an adjunct in Biomedical and Health Informatics in the School of Medicine at the University of Washington. We spoke with her about patient-facing technologies, including the opportunities and challenges for patient safety.


The Role of Patient-facing Technologies to Empower Patients and Improve Safety

Patient-facing Technologies: Opportunities and Challenges for Patient Safety, November 2017

Ronen Rozenblum, MD, MPH, and David Bates, MD, MS

This piece explores how patient-facing technologies can enable patients to be more responsible for their care and improve the way clinicians practice.

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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?

Medication groups that trigger drug allergy alerts.


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Upcoming & Noteworthy

TeamSTEPPS Master Training Course: An Active Approach to Learning and Teaching TeamSTEPPS.

AHA Team Training. December 14–15, 2017; American Hospital Association, Chicago, IL.

SIDM Diagnostic Fellowship.

Society to Improve Diagnosis in Medicine.

View Upcoming Events

Most Viewed


The natural history of recovery for the healthcare provider "second victim" after adverse patient events.

Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. Qual Saf Health Care. 2009;18:325-330.

Newspaper/Magazine Article

Pharmacists play key role in patient safety.

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


Report on the Safe Use of Pick Lists in Ambulatory Care Settings.

Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.