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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

Decisions and repercussions of second victim experiences for mothers in medicine (SAVE DR MoM).

Gupta K, Lisker S, Rivadeneira NA, et al. BMJ Qual Saf. 2019 Feb 4; [Epub ahead of print].

How to be a very safe maternity unit: an ethnographic study.

Liberati EG, Tarrant C, Willars J, et al. Soc Sci Med. 2019;223:64-72.

Does overlapping surgery result in worse surgical outcomes? A systematic review and meta-analysis.

Gartland RM, Alves K, Brasil NC, et al. Am J Surg. 2018 Dec 8; [Epub ahead of print].

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

Meyer AND, Singh H. JAMA. 2019 Feb 8; [Epub ahead of print].

A cognitive forcing tool to mitigate cognitive bias—a randomised control trial.

O'Sullivan ED, Schofield SJ. BMC Med Educ. 2019;19:12.

Opioid prescribing trends and the physician’s role in responding to the public health crisis.

Adams JM, Giroir BP. JAMA Intern Med. 2019 Feb 11; [Epub ahead of print].

Three laws for paperlessness.

Thimbleby H. Digit Health. 2019;5:2055207619827722.

The impact of RVU-based compensation on patient safety outcomes in outpatient otolaryngology procedures.

Stanisce L, Ahmad N, Deckard N, et al. Otolaryngol Head Neck Surg. 2019 Feb 5; [Epub ahead of print].


AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report.

Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.

Newspaper/Magazine Article

Pro/con debate: color-coded medication labels.

Janik LS, Vender JS  Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.

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?

Barriers to patients speaking up about care concerns in the ICU.


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Upcoming & Noteworthy

ACHE Congress on Healthcare Leadership.

American College of Healthcare Executives. March 4–7, 2019; Hilton Chicago, Chicago, IL.

Speak Up Initiative.

Oakbrook Terrace, IL: Joint Commission.

View Upcoming Events

Most Viewed


Residents' response to duty-hour regulations—a follow-up national survey.

Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.


Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.


Creating an oversight infrastructure for electronic health record–related patient safety hazards.

Singh H, Classen DC, Sittig DF. J Patient Saf. 2011;7:169-174.