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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

Scaling safety: the South Carolina Surgical Safety Checklist experience.

Berry WR, Edmondson L, Gibbons LR, et al. Health Aff (Millwood). 2018;37:1779-1786.

Adverse events and patient outcomes among hospitalized children cared for by general pediatricians vs hospitalists.

Atkinson MK, Schuster MA, Feng JY, Akinola T, Clark KL, Sommers BD. JAMA Netw Open. 2018;1:e185658.

Association of opioid prescriptions from dental clinicians for US adolescents and young adults with subsequent opioid use and abuse.

Schroeder AR, Dehghan M, Newman TB, Bentley JP, Park KT. JAMA Intern Med. 2018 Dec 3; [Epub ahead of print].

The effect of cognitive load and task complexity on automation bias in electronic prescribing.

Lyell D, Magrabi F, Coiera E. Hum Factors. 2018;60:1008-1021.

Lessons learned from implementing a principled approach to resolution following patient harm.

Smith KM, Smith LL, Gentry JC, Mayer DB. J Patient Saf Risk Manag. 2018 Dec 3; [Epub ahead of print].


Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.

Framework for Effective Board Governance of Health System Quality.

Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.


2019 National Patent Safety Goals: A Focus on Current Issues.

Joint Commission Resources Quality and Safety Network. January 24, 2019; 2:00–3:00 PM (Eastern).

Action Planning for the SOPS Surveys Webcast.

Agency for Healthcare Research and Quality. January 17, 2019; 12:00–1:00 PM (Eastern).

2019 Virginia Patient Safety Summit.

Virginia Hospital & Healthcare Association. January 30–February 1, 2019; Downtown Richmond Marriott, Richmond, VA.

Latest WebM&M Issue

Expert analysis of medical errors.

Spotlight: Mistaken Attribution, Diagnostic Misstep

  • Spotlight Case
  • CE/MOC

Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD, January 2019

A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).

Critical Order Set Change and Critical Limb Ischemia

Brian Clay, MD, January 2019

Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).

One Bronchoscopy, Two Errors

Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD, January 2019

Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.

Annual Perspective

Audrey Lyndon, RN, PhD, 2018

This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.

Annual Perspective

Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018

Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.

View All Annual Perspectives

Patient Safety Primers

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

View All Primers

Did You Know?

Patients with low visual ability have higher risk of acetaminophen self-dosing errors.


View All DYKs

Upcoming & Noteworthy

TeamSTEPPS Master Training Course.

AHA Team Training. April 1–November 5, 2019.

Patient Safety Executive Development Program.

Institute for Healthcare Improvement. March 7–13, 2019, Charles Hotel, Cambridge, MA.

View Upcoming Events

Most Viewed


Sponges, tools and more left inside Washington hospital patients.

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


Medication reconciliation at hospital discharge: evaluating discrepancies.

Wong JD, Bajcar JM, Wong GG, et al. Ann Pharmacother. 2008;42:1373-1379.

Newspaper/Magazine Article

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.