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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

Visual acuity, literacy, and unintentional misuse of nonprescription medications.

Mullen RJ, Curtis LM, O'Conor R, et al. Am J Health Syst Pharm. 2018;75:e213-e220.

Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.

Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].

Fake it 'til you make it: pressures to measure up in surgical training.

Patel P, Martimianakis MA, Zilbert NR, et al. Acad Med. 2018;93:769-774.

Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service.

Lord K, Parwani V, Ulrich A, et al. Am J Emerg Med. 2018 Mar 20; [Epub ahead of print].

Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study.

Kristensen RU, Nørgaard A, Jensen-Dahm C, Gasse C, Wimberley T, Waldemar G. J Alzheimers Dis. 2018;63:383-394.

Opportunities to improve informed consent with AHRQ training modules.

Shoemaker SJ, Brach C, Edwards A, Chitavi SO, Thomas R, Wasserman M. Jt Comm J Qual Patient Saf. 2018;44:343-352.

Press Release/Announcement

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. May 24, 2018.


Sentinel Events Update: Improving Root Cause Analyses and Actions to Prevent Harm.

Joint Commission Resources Quality and Safety Network. August 23, 2018; 2:00–3:00 PM (Eastern).

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?

Most common outpatient medication errors in children younger than 6.


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Upcoming & Noteworthy

TeamSTEPPS National Conference.

AHA Team Training. June 20–22, 2018. Manchester Grand Hyatt San Diego, San Diego, CA.

Design for Patient and Staff Safety: A Systems Approach.

The Center for Health Design. June 25–26, 2018; Hyatt Centric Chicago Magnificent Mile, Chicago, IL.

View Upcoming Events

Most Viewed


Laboratory safety monitoring of chronic medications in ambulatory care settings.

Hurley JS, Roberts M, Solberg LI, et al. J Gen Intern Med. 2005;20:331-333. 


Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data.

Abel GA, Mendonca SC, McPhail S, Zhou Y, Elliss-Brookes L, Lyratzopoulos G. Br J Gen Pract. 2017;67:e377-e387.