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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

The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review.

Mossburg SE, Dennison Himmelfarb C. J Patient Saf. 2018 Jun 25; [Epub ahead of print].

I-PASS handoff program: use of a campaign to effect transformational change.

Rosenbluth G, Destino LA, Starmer AJ, et al. Pediatr Qual Saf. 2018 Jul 20; [Epub ahead of print].

Evaluation of the frequency of dispensing electronically discontinued medications and associated outcomes.

Copi EJ, Kelley LR, Fisher KK. J Am Pharm Assoc (2003). 2018;58(suppl 4):S46-S50.

Thematic analysis of women's perspectives on the meaning of safety during hospital-based birth.

Lyndon A, Malana J, Hedli LC, Sherman J, Lee HC. J Obstet Gynecol Neonatal Nurs. 2018;47:324-332.

Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments.

François P, Lecoanet A, Caporossi A, Dols AM, Seigneurin A, Boussat B. PLoS One. 2018;13:e0201067.

Drawing boundaries: the difficulty in defining clinical reasoning.

Young M, Thomas A, Lubarsky S, et al. Acad Med. 2018;93:990-995.

Press Release/Announcement

AHRQ Announces Interest in Health Services Research to Address the Opioids Crisis.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. August 2, 2018. Publication No. NOT-HS-18-015.


Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.


ASHP guidelines on managing drug product shortages.

Fox ER. Am J Health Syst Pharm. 2018 Jul 30; [Epub ahead of print].

Web Resource

International Patient Safety Day.

September 17, 2018; Coalition for Patient Safety, German Federal Ministry of Health, Berlin, DE.

Latest WebM&M Issue

Expert analysis of medical errors.

Abdominal Aortic Aneurysm Screening

  • Spotlight Case

Jeffrey Jim, MD, MPHS, August 2018

An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.

An Untimely End Despite End-of-Life Care Planning

Giovanni Elia, MD; Susan Barbour, RN, MS; and Wendy G. Anderson, MD, MS, August 2018

Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members. Another nurse found the canceled orders, thought it was an error, and asked another physician (who was also unaware of the change in plans) to reinstate the orders. The patient was extubated and died a few hours later.

Mixup Beyond the Medication Label

Helen Pervanas, PharmD, RPh, and David VanValkenburgh, August 2018

Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Matthew Weinger, MD

Update on Simulation, August 2018

Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthesiology, Biomedical Informatics, and Medical Education at Vanderbilt University. He holds the Norman Ty Smith Chair in Patient Safety and Medical Simulation. We spoke with him about the current state of simulation training in health care, barriers to progress, and potential innovations.


How Does Health Care Simulation Affect Patient Care?

Update on Simulation, August 2018

Joseph O. Lopreiato, MD, MPH

This piece explores health care simulation including the four main methods used and the evidence base for its impact on learning and patient care.

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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?

Common types of medication errors occurring outside health care settings.


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Upcoming & Noteworthy

Diagnostic Error in Medicine 2018: Second European Conference.

Society to Improve Diagnosis in Medicine and Patient Safety Switzerland. August 30–31, 2018, Inselspital University Hospital, Bern, Switzerland.

2018 APSF Stoelting Conference Perioperative Medication Safety: Advancing Best Practices.

Anesthesia Patient Safety Foundation. September 5–6, 2018; Royal Palms Resort and Spa, Phoenix, AZ.

Revised Guidelines for Safe Use of Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; July 26, 2018.

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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.


Exploring approaches to patient safety: the case of spinal manipulation therapy.

Rozmovits L, Mior S, Boon H. BMC Complement Altern Med. 2016;16:164.


Raising the awareness of inpatient nursing staff about medication errors.

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