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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

National quality program achieves improvements in safety culture and reduction in preventable harms in community hospitals.

Frush K, Chamness C, Olson B, et al. Jt Comm J Qual Patient Saf. 2018 Jun 5; [Epub ahead of print].

Association of opioid-related adverse drug events with clinical and cost outcomes among surgical patients in a large integrated health care delivery system.

Shafi S, Collinsworth AW, Copeland LA, et al. JAMA Surg. 2018 May 23; [Epub ahead of print].

Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system.

Whalen K, Lynch E, Moawad I, John T, Lozowski D, Cummings BM. J Am Med Inform Assoc. 2018 Apr 23; [Epub ahead of print].

Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study.

Usher M, Sahni N, Herrigel D, et al. J Gen Intern Med. 2018 May 29; [Epub ahead of print].

Association of hospital participation in a regional trauma quality improvement collaborative with patient outcomes.

Hemmila MR, Cain-Nielsen AH, Jakubus JL, Mikhail JN, Dimick JB. JAMA Surg. 2018 May 2; [Epub ahead of print].

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

Krein SL, Mayer J, Harrod M, et al. JAMA Intern Med. 2018 Jun 11; [Epub ahead of print].

Evaluation of reasons why surgical residents exceeded 2011 duty hour requirements when offered flexibility.

Blay E Jr, Engelhardt KE, Hewitt DB, Dahlke AR, Yang AD, Bilimoria KY. JAMA Surg. 2018 Jun 13; [Epub ahead of print].

Newspaper/Magazine Article

Special or Theme Issue

The Science of Teamwork.

McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.

Journal of Patient Safety and Risk Management.

Wu AW, ed. Thousand Oaks, CA: SAGE Publications. ISSN: 2516-0435.

Press Release/Announcement

FDA Safety Communication: recommendations to reduce surgical fires and related patient injury.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.


Diagnostic Error and the Diagnostic Process Conference Series.

Ohio Hospital Association. July 18, 2018–January 9, 2019.

Latest WebM&M Issue

Expert analysis of medical errors.

Chest Pain in a Rural Hospital

  • Spotlight Case

A. Clinton MacKinney, MD, MS, and Nicholas M. Mohr, MD, MS, June 2018

After presenting to a rural emergency department with chest pain, a man with a history of diabetes awaited admission to the hospital. The off-site admitting internist ordered aspirin and a heparin drip, but neither medication was administered. On transfer to the acute care unit 2 hours later, the patient was diaphoretic, somnolent, tachycardic, and borderline hypotensive. The nurse called the internist and realized the heparin drip had never been started. When she went to administer it, the patient was unresponsive, hypotensive, and bradycardic. She called a code blue.

Febrile Neutropenia and an Almost Fatal Medication Error

Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH, June 2018

Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository. The patient developed a fever soon after receiving the suppository and required transfer to the intensive care unit for hypotension and management of septic shock.

Perils in Diagnosing a Stroke

Joseph L. Schindler, MD, June 2018

Brought to the emergency department after being found unresponsive, an older man was given systemic thrombolytics to treat a suspected stroke. After administering the medication, the nurse noticed patches on the patient's back. The patient's wife explained that the patches, which contained fentanyl and whose doses had recently been increased, were for chronic back pain. In fact, the wife had placed two patches that morning. Medication reconciliation revealed that the patient had inadvertently received 3 times his previous dose. He was administered naloxone to treat the opioid overdose. Although he became more responsive, he had a generalized seizure and a CT showed intracranial hemorrhage—an adverse consequence of the thrombolytics.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Richard Hoppmann, MD

Point-of-Care Ultrasound: Safety and Utility, June 2018

Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Director of the Ultrasound Institute of the University of South Carolina School of Medicine. He founded and served as the first President of the Society of Ultrasound in Medical Education. We talked to him about safety and usability of point-of-care ultrasound.


Safety Considerations in Building a Point-of-Care Ultrasound Program

Point-of-Care Ultrasound: Safety and Utility, June 2018

Chris Moore, MD

This piece highlights how point-of-care ultrasound can improve and expedite diagnosis and advocates for having an individual responsible for overseeing point-of-care ultrasound use within a health care delivery organization.

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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

AATS Surgical Patient Safety Course 2018.

American Association for Thoracic Surgery. June 29–30, 2018; Renaissance Boston Waterfront Hotel, Boston, MA.

Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.

Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.

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Most Viewed


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

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


Sponges, tools and more left inside Washington hospital patients.

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


Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.