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Promoting Patient Safety.
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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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
The PSNet Collection
March 15, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.
Training and Education
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.
A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were... Read More
A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life... Read More
This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the... Read More
A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time,... Read More
The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause... Read More
Upcoming Events
The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.
Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.
