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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

Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017.

Vivolo-Kantor AM, Seth P, Gladden RM, et al. MMWR Morb Mortal Wkly Rep. 2018;67:279-285.

Impact of a national QI programme on reducing electronic health record notifications to clinicians.

Shah T, Patel-Teague S, Kroupa L, Meyer AND, Singh H. BMJ Qual Saf. 2018 Mar 5; [Epub ahead of print].

The accuracy of trigger tools to detect preventable adverse events in primary care: a systematic review.

Davis J, Harrington N, Bittner Fagan H, Henry B, Savoy M. J Am Board Fam Med. 2018;31:113-125.

Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey.

Stoklosa H, Scannell M, Ma Z, Rosner B, Hughes A, Bohan JS. Emerg Med J. 2018 Feb 3; [Epub ahead of print].

Pediatric adverse event rates associated with inexperience in teaching hospitals: a multilevel analysis.

Dynan L, Goudie A, Brady PW. J Healthc Qual. 2018;40:69-78.

A national study links nurses' physical and mental health to medical errors and perceived worksite wellness.

Melnyk BM, Orsolini L, Tan A, et al. J Occup Environ Med. 2018;60:126-131.


Critical Deficiencies at the Washington DC VA Medical Center.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.

Patient Deaths at Arbour Health Systems—Westwood Lodge Hospital and Pembroke Hospital.

Disability Law Center. Boston, MA: February 2018.


Many women come close to death in childbirth.

Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.

Latest WebM&M Issue

Expert analysis of medical errors.

Isolated Clot, Real Error

  • Spotlight Case

Anna Parks, MD, and Margaret C. Fang, MD, MPH , March 2018

One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.

Shortcuts to Acetaminophen-induced Liver Failure

Stephen Bacak, DO, MPH, and Loralei Thornburg, MD, March 2018

A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.

Missing ECG and Missed Diagnosis Lead to Dangerous Delay

Robert E. O'Connor, MD, MPH, March 2018

Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Linda Aiken, PhD, RN

Nursing and Patient Safety, March 2018

Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.


Missed Nursing Care: A Key Measure for Patient Safety

Nursing and Patient Safety, March 2018

Jane Ball, PhD, and Peter Griffiths, PhD

This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.

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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?

Patient-perceived harm associated with care breakdowns.


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Upcoming & Noteworthy

2018 International Symposium on Human Factors and Ergonomics in Health Care.

Human Factors and Ergonomics Society. March 26–28, 2018; Marriott Copley Place, Boston, Massachusetts.

CUSP Implementation Workshop.

Armstrong Institute for Patient Safety and Quality. April 3, 2018; Constellation Energy Building Conference Center, Baltimore, MD.

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Most Viewed


Raising the awareness of inpatient nursing staff about medication errors.

Elnour AA, Ellahham NH, Al Qassas HI. Pharm World Sci. 2008;30:182-190.


Sponges, tools and more left inside Washington hospital patients.

Ryan J. KUOW. National Public Radio. August 1, 2013.


Final Report of the Commission on Care.

Washington, DC: Commission on Care; June 2016.