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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 free CME 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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Medication Errors/Preventable Adverse Drug Events
Culture of Safety
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The PSNet Collection

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December 6, 2023 Weekly Issue

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

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Review
The relationship between nursing home staffing and resident safety outcomes: a systematic review of reviews.
Blatter C, Osińska M, Simon M, et al. Int J Nurs Stud. 2023;150:104641.
Minimum nurse staffing levels have been promoted by researchers and legislators to reduce adverse events and improve patient safety in both hospitals and nursing homes. While this review of reviews found higher nurse staffing was generally associated with positive outcomes, results varied between staffing groups (e.g., registered nurses compared to licensed vocational/practical nurses or nursing...
Review
The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant black women: a review of the literature.
Montalmant KE, Ettinger AK. J Racial Ethn Health Disparities. 2023;Epub Nov 13.
The increased risk of maternal morbidity and mortality among Black women in the United States is a patient safety and public health crisis. This literature review of 42 articles highlights the importance of cultural competence and disparities training for obstetric providers to reduce maternal mortality and morbidity among Black women. The authors also highlight the need for increased awareness regarding...
Commentary
Community Health Systems’ ongoing journey to zero preventable harm.
Simon LT, Van Buren T. NEJM Catal Innov Care Deliv. 2023;4.
Achieving zero preventable harm is an ongoing goal for healthcare organizations. This article describes one large, multistate community health system’s experience decreasing serious adverse events through implementation of high-reliability leadership, promoting human error prevention behaviors, and accelerating learning through a structured approach to cause analysis at both the individual and systems...
Study
Completion of recommended tests and referrals in telehealth vs in-person visits.
Zhong A, Amat MJ, Anderson TS, et al. JAMA Netw Open. 2023;6:e2343417.
Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or...

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Training and Education

Update Date: November 30, 2023

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 CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

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New
Medication Mix-Up Leads to Patient Death
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... Read More

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

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Toolkits

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

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