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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.

PSNet Weekly Update

What's new in patient safety literature, news, & more.
Study

Latest WebM&M Issue

Expert analysis of medical errors.

WebM&M Cases
“This is the wrong patient’s blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Spotlight Case
CE/MOC
Sarah Barnhard, MD,  
A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement. He had multiple home medications and was also on Warfarin, which was held appropriately prior to the surgery.  A Type and Cross for blood request was sent along with baseline labs; however, there was a mislabeling error on one of the samples causing a delay in the blood getting to the operating room resulting in the medical team initiating a massive transfusion protocol when the patient became hypotensive.
Patient Identification Errors: A Systems Challenge
Lamia S. Choudhury, MS1 and Catherine T Vu, MD,  
Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.
Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Nasim Wiegley, M.D. and José A. Morfín, M.D. ,  
A 54-year-old man was found unconscious at home with multiple empty bottles of alcoholic beverages nearby and was brought to the emergency department by his family members. He was confused and severely hyponatremic, so he was admitted to the intensive care unit (ICU). His hospital stay was complicated by an error in the administration of hypertonic saline.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Interview
In Conversation With... David Gruen, MD
Emerging Safety Issues in Artificial Intelligence

David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and content expert for artificial intelligence in medical imaging. We spoke with him about the role artificial intelligence can play in healthcare diagnostics and the potential for reducing diagnostic errors.

Perspective
Artificial Intelligence and Diagnostic Errors
Emerging Safety Issues in Artificial Intelligence

This piece discusses the current use of artificial intelligence in diagnostic imaging and key patient safety considerations.

View more information.

Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

Upcoming & Noteworthy

Meeting/Conference
Upcoming Meeting/Conference
International Society for Quality in Health Care Conference

International Society for Quality in Health Care. Centro Regionale Gestione Rischio Clinico e Sicurezza del Paziente (GRC) and the Italian Network for Safety in Healthcare, ISQua. 30th August - 2nd September 2020

Audiovisual
Audiovisual Presentation
SOPS Surveys.
AHRQ; Agency for Healthcare Research and Quality.

Most Viewed

Web Resource
Government Resource
Better Safer Care Victoria.
Safer Care Victoria and Victorian Agency for Health Information. Better Safer Care Victoria. https://www.bettersafercare.vic.gov.au/