U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Submit a Case
Patient Safety Network
Users can now browse by Clinical Areas: View content tailored to specific areas of interest, like Primary Care, Hospital Medicine, Pharmacy, and more.

Promoting Patient Safety.

Advanced Search
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 Learn More About Patient Safety Browse by Clinical Areas

Popular Searches

Medication Errors/Preventable Adverse Drug Events
Psychological and Social Complications
Culture of Safety
Communication between Providers
Discontinuities, Gaps, and Hand-Off Problems

The PSNet Collection

-
RESOURCES
-
PERSPECTIVES
-
WEBM&Ms
-
PRIMERS

November 29, 2023 Weekly Issue

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

View the Weekly Issue
RSS Feed
Study
Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems.
Metz VE, Ray GT, Palzes V, et al. J Gen Intern Med. 2023;Epub Nov 6.
In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality...
Study
Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS).
Ravindran S, Matharoo M, Rutter MD, et al. Endoscopy. 2023;Epub Sept 18.
Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification...
Study
Overnight stay in the emergency department and mortality in older patients.
Roussel M, Teissandier D, Yordanov Y, et al. JAMA Intern Med. 2023;Epub Nov 6.
Overcrowding in the emergency department (ED) can result in long wait times to be seen or admitted, as well as placing patients at increased risk of adverse events. In this prospective study, researchers compared the risk of in-hospital mortality among older patients who spent a night in the ED waiting for admission to the hospital versus older patients who were admitted to the hospital before midnight....

Browse by Clinical Areas

View All Clinical Areas
Sign up for PSNet Issues today!
Go to AHRQ site and subscribe

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.

View Training and Education
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

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

View All 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.
Create a Library
(Requires Login to PSNet Account)
Back To Top
Terms and Conditions | Privacy Policy | External Link Disclaimer | RSS Feed

Connect With Us

Facebook Twitter You Tube LinkedIn

Sign up for Email Updates

Agency for Healthcare Research and Quality

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364

Submit Your Innovations