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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

Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.

Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018 Jul 9; [Epub ahead of print].

Centers for Medicare and Medicaid services hospital-acquired conditions policy for central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement.

Calderwood MS, Kawai AT, Jin R, Lee GM. Infect Control Hosp Epidemiol. 2018 Jun 28; [Epub ahead of print].

The burden of opioid-related mortality in the United States.

Gomes T, Tadrous M, Mamdani MM, Paterson JM, Juurlink DN. JAMA Network Open. 2018;1:e180217.

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up.

Alingh CW, van Wijngaarden JDH, van de Voorde K, Paauwe J, Huijsman R. BMJ Qual Saf. 2018 Jun 28; [Epub ahead of print].

A conceptual framework to reduce inpatient preventable deaths.

Davis DP, Aguilar SA, Lawrence B, Minokadeh A, Sell SE, Husa RD. Jt Comm J Qual Patient Saf. 2018;44:413-420.

Newspaper/Magazine Article

ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2.

ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.


No Place Like Home: Advancing the Safety of Care in the Home.

Boston, MA: Institute for Healthcare Improvement; 2018.

Delivering Quality Health Services: A Global Imperative for Universal Health Coverage.

Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.


2017 John M. Eisenberg Patient Safety and Quality Awards.

Jt Comm J Qual Patient Saf. 2018;44:373-400.

Web Resource

Master of Healthcare Quality and Safety.

Harvard Medical School. Boston, MA.


Health IT Patient Safety Supplemental Items for Hospitals.

Agency for Healthcare Research and Quality. July 25, 2018; 2:00–2:50 PM (Eastern).

Latest WebM&M Issue

Expert analysis of medical errors.

"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety

  • Spotlight Case

Resa E. Lewiss, MD, July 2018

After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.

Don't Pick the PICC

Rita L. McGill, MD, MS, July 2018

Admitted to the hospital with an ulcer on his right foot, a man with diabetes and stage IV chronic kidney disease had an MRI concerning for osteomyelitis, and a bone biopsy showed chronic inflammation with cultures positive for methicillin-sensitive Staphylococcus aureus. To administer outpatient parenteral antimicrobial therapy, interventional radiology attempted to place a peripherally inserted central catheter (PICC) in the right brachial vein multiple times but failed. They then placed it in the left brachial vein. The patient completed 6 weeks of antibiotic therapy and wound care, and the PICC was removed. Five months later with worsening renal function and hyperphosphatemia, the patient required dialysis access, but he was not a candidate for arteriovenous fistula placement since the many venipuncture attempts during PICC placement resulted in poor vein quality.

Primary Workaround, Secondary Complication

Deborah Debono, PhD, RN, and Tracy Levett-Jones, PhD, RN, July 2018

A young adult with a progressive neurological disorder presented to an emergency department from a nursing home with a dislodged GJ tube. As a workaround to maintain patency when the GJ tube was dislodged, nursing home staff had inserted a Foley catheter into the ostomy, inflated the Foley bulb in the stomach, and tied the distal portion of the catheter in a loose knot. When the patient went to interventional radiology for new GJ tube placement, clinicians found no Foley but inserted a new GJ tube. Discharged to the nursing home, the patient was readmitted 2 days later with fever and increasing abdominal distention. An abdominal CT scan showed an obstructing foreign body in the small bowel.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Gordon Schiff, MD

Improving Diagnosis, July 2018

Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School, and Quality and Safety Director for the Harvard Medical School Center for Primary Care. He was an invited expert and reviewer for the Improving Diagnosis in Health Care report of the National Academy of Medicine. We spoke with him about understanding and preventing diagnostic errors.


In Conversation With… Shantanu Nundy, MD

Improving Diagnosis, July 2018

Dr. Nundy is the Director of the Human Diagnosis Project, a nonprofit organization taking a unique crowdsourcing approach to improving medical diagnosis. He also practices primary care at a federally qualified health center for low-income and uninsured individuals in Washington, DC. We spoke with him about his work with the Human Diagnosis Project.

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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?

Top 10 patent-reported care breakdowns.


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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.

AHRQ Safety Program for Improving Antibiotic Use.

Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, University of Chicago.

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Most Viewed

Newspaper/Magazine Article

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.


Eliminating adverse drug events at Ascension Health.

Butler K, Mollo P, Gale JL, Rapp DA. Jt Comm J Qual Patient Saf. 2007;33:527-536.


Raising the awareness of inpatient nursing staff about medication errors.

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