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Promoting Patient Safety.

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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for CE without a fee and trainings. The platform provides powerful searching and browsing capability, as well as the ability for users to customize the site around their interests (My Profile).

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January 22, 2025 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.

Study
Abdo A, Gallay L, Vallecillo T, et al. Sci Rep. 2024;14:32022.
Pharmacist-led medication reconciliation is resource intensive; targeting patients most at risk for medication errors can make the best use of this limited resource. In this study, a machine learning (ML) tool was developed to identify hospitalized patients at risk of medication errors. As standard practice in the study hospital, a pharmacist selected a small random sample of patients for medication...
Study
Bradford A, Tran A, Ali KJ, et al. J Gen Intern Med. . 2024;Epub Oct 22.
AHRQ’s Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events supports organizational efforts to reduce diagnostic errors. This article describes the efforts of 11 healthcare organizations' implementation and six-month sustainment of Measure Dx. Each of the four case-finding strategies was used, 703 cases were reviewed, and 32% of cases had at least one diagnostic...
Study
Wesevich A, Langan E, Fridman I, et al. JAMA Netw Open. 2024;7:e2450172.
Bias and the use of stigmatizing language can compromise patient care. This study, conducted with medical students and residents at two academic medical centers, examined the impact of biased versus neutral language on clinical information recall and attitudes towards patients during simulated handoffs. Findings indicate that biased language (particularly blame-based bias) led to less accurate...
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Training and Education

Update Date: December 18, 2024

WebM&M Case Studies & Spotlight Cases

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CE. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

Spotlight Case
CME/MOC
CPE
Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Lewis, MD | December 31, 2024

A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with... Read More

Christian Bohringer, MBBS and Hong Liu, MD | December 18, 2024

After drowning in a pool, a 19-month-old child arrived at the ED in respiratory distress, requiring intubation and mechanical ventilation. The patient’s SpO2 did... Read More

Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

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Improvement Resources
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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

Toolkit
Toolkits

Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.

Create Your Own Library

Create your own library to save and manage content on any topic of interest. You can start by searching for articles or by creating your library right here.