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AHRQ: Agency for Healthcare Research and Quality
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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
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May 24, 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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Study
Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries.
Armstrong AA. J Healthc Qual. 2023;45:125-132.
Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions, and lower quality of life. This article describes the experience of one hospital which, after it discovered it had higher-than-average HAPI rates, conducted a root cause analysis to determine contributing factors and identify potential solutions. Dedicated nursing staff were hired and trained, and...
Study
The impact of a nursing-led intervention bundle with a bedside checklist to reduce mortality during the initial COVID-19 pandemic and implications for future emergencies.
Pugh S, Chan F, Han S, et al. J Nurs Adm. 2023;53:292-298.
The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions....
Study
Attitudes of clinicians and patient safety culture before and after the ARRIVE trial.
White VanGompel E, Carlock F, Singh L, et al. J Obstet Gynecol Neonatal Nurs. 2023;52:211-222.
Cesarean delivery can lead to increased maternal morbidity and mortality. In this repeated cross-sectional study, physicians, nurses, and midwives were surveyed about their attitudes towards elective induction of labor before and after results were published from a large, randomized trial (Randomized Trial of Induction Versus Expectant Management, or ARRIVE) supporting elective inductions at 39 weeks to...
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Training and Education

Update Date: April 26, 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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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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Innovations

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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Telephone: (301) 427-1364

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