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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 31, 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
Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial.
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;Epub May 17.
Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful...
Study
Patients admitted on weekends have higher in-hospital mortality than those admitted on weekdays: analysis of national inpatient sample.
Manadan A, Arora S, Whittier M, et al. Am J Med Open. 2023;9:100028.
The ”weekend effect” refers to worse outcomes among patients admitted on the weekend versus weekday. Based on a sample of over 121 million adult hospital discharges from 2016 to 2019, researchers examined the association between several different variables and in-hospital death. Multivariable analyses identified several predictors of in-hospital death (e.g., older age, higher number of comorbidities, etc...
Study
The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.
Ross P, Hodgson CL, Ilic D, et al. Contemp Nurse. 2023;Epub May 8.
Improved nurse staffing ratios and nursing skill mix have been linked to improved safety outcomes. This retrospective cohort study of over 13,000 patients admitted to a tertiary intensive care unit (ICU) in Australia between 2016 and 2020 found that a great concentration of critical care registered nurses (CCRNs) was associated with a lower risk of adverse events.
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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?
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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The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

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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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