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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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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

January 12, 2022 Weekly Issue

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

Review
Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2021;Epub Dec 22.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Study
Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163(1):83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
Study
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48(1):12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
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Training and Education

Update Date: January 7, 2022

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.

Candice Sauder, MD, MS, MEd, FACS and Kara T Kleber, MD, MA | January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several... Read More

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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.