Skip to main content
Learn about how to register and explore PSNet's new personalization options. Find out More.

Promoting Patient Safety.

Search Tips

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).

Browse the Collection

Popular Searches

What is Patient Safety?

The breadth of the field of patient safety is captured in various definitions. It has been defined as avoiding harm to patients from care that is intended to help them.1 It involves the prevention and mitigation of harm caused by errors of omission or commission in healthcare, and the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.2

A nurse and her patient, a person washing their hands over a sink, and 2 medical professionals looking at a tablet.

The PSNet Collection

February 8, 2023 Weekly Issue

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

Review
Farzandipour M, Nabovati E, Sharif R. J Telemed Telecare. 2023;Epub Jan 23.
Remote triage allows patients to receive guidance about whether to seek care and, if required, what level of care. This review of remote triage focuses exclusively on tele-triage studies conducted during the COVID-19 pandemic. The studies reported on five broad outcome categories (access to care, triage rates, patient safety, post-triage clinical outcomes, and patient satisfaction) with highly positive outcomes.
Study
Fridman M, Korst LM, Reynen DJ, et al. Jt Comm J Qual Patient Saf. 2022;Epub Nov 19.
Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.
Study
Namiranian, MD, PhD K. J Opioid Manag. 2023;19:69-76.
Prescription opioids are commonly used to manage surgical and non-surgical pain but misuse of opioids is a serious patient safety concern. In this retrospective cohort study of Veterans Health Administration patients, researchers found that opioid misuse among previously opioid-naïve patients increases significantly after 11 months of chronic use, regardless of whether the opioid was prescribed for surgical or non-surgical pain.
Sign up for PSNet Issues today!

Training and Education

Update Date: February 1, 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.

Craig Keenan, MD, Scott MacDonald, MD, Ashley Takeshita, and Dale Sapell, PharmD | February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for... Read More

Take the Quiz
Elizabeth Partridge, MD, MPH, Daniel Dodson, MD, MS, Mary Reilly, MHA, BSN, RN, CIC and Stuart H. Cohen, MD | February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems,... Read More

Dahlia Zuidema, PharmD, Berit Bagley, MSN, and Charity L Tan MSN | February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication... Read More

Nicole A. Weiss, MD | February 1, 2023

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter... Read More

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.

Upcoming Events

Improvement Resources
Bulb
Innovations

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

Toolkit
Toolkits

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

Create Your Own Library

Create your own library to save and manage content on any topic of interest. You can start by searching for articles or by creating your library right here.