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PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more.

Journal Article

Clinician perspectives on electronic health records, communication, and patient safety across diverse medical oncology practices.

Patel MR, Friese CR, Mendelsohn-Victor K, et al. J Oncol Pract. 2019;15:e529-e536.

Serious misdiagnosis-related harms in malpractice claims: the "Big Three"—vascular events, infections, and cancers.

Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Diagnosis (Berl). 2019 Jul 11; [Epub ahead of print].

'Poking the skunk': ethical and medico-legal concerns in research about patients' experiences of medical injury.

Schulz Moore J, Mello MM, Bismark M. Bioethics. 2019 Jun 20; [Epub ahead of print].

Safety-I, Safety-II and burnout: how complexity science can help clinician wellness.

Smaggus A. BMJ Qual Saf. 2019 Jun 13; [Epub ahead of print].

Evaluating a handheld decision support device in pediatric intensive care settings.

Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61.

Patient safety superheroes in training: using a comic book to teach patient safety to residents.

Maatman TC, Prigmore H, Williams JS, Fletcher KE. BMJ Qual Saf. 2019 Jun 14; [Epub ahead of print].

Special or Theme Issue

2018 John M. Eisenberg Patient Safety and Quality Awards.

Jt Comm J Qual Patient Saf. 2019;45:461-486.


Independent Review of Gross Negligence Manslaughter and Culpable Homicide.

Manchester, UK: General Medical Council; June 2019.

Web Resource

Patient Safety Learning.

China Works, SB220, 100 Black Prince Road, Vauxhall, London, SE1 7SJ.


Better Maternal Outcomes Rapid Improvement Network: Community and Safety-Net Hospitals.

Institute for Healthcare Improvement. September 2019–February 2020.

Latest WebM&M Issue

Expert analysis of medical errors.

Diuretics and Electrolyte Abnormalities

  • Spotlight Case
  • CE/MOC

Tobias Dreischulte, MPharm, MSc, PhD, July 2019

During a primary care visit, a woman with morbid obesity, chronic obstructive pulmonary disease, hypertension, heart failure, and diabetes mellitus complained of worsening lower extremity edema over the past few weeks. Her physician prescribed a thiazide diuretic. The patient presented to the emergency department (ED) 10 days later with 3 days of drowsiness and confusion. Laboratory results revealed severe hyponatremia and hypokalemia. She had a seizure in the ED and was admitted to the intensive care unit. Both the critical care provider and a nephrologist felt the diuretic had caused the electrolyte abnormalities.

Delayed Clozapine Prescription in an Elderly Man With Dementia

Candy Tsourounis, PharmD, and Katayoon Kathy Ghomeshi, PharmD, July 2019

An elderly man admitted for agitation and suicidal ideation was prescribed clozapine by psychiatry. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program requires both prescribers and patients to be registered in an online database. A REMS-registered attending psychiatrist entered the initial order (12.5 mg). During the hospitalization, the medicine intern, who was not registered with the REMS program, titrated the dose to 25 mg daily and also wrote the discharge prescription. The outpatient pharmacist noted the intern was not registered and contacted the attending psychiatrist, who wrote a new prescription. The patient's family was unable to pick up the prescription for 3 days. During this gap in therapy, the patient experienced recurrence of paranoia and required readmission to the hospital.

Failure to Rescue the Mother

Melissa S. Wong, MD; Angelica Vivero, MD; Ellen B. Klapper, MD; and Kimberly D. Gregory, MD, MPH, July 2019

First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused. A rash developed surrounding the transfusion site and widespread ecchymosis appeared as she became more unstable. Although physicians attempted to stabilize her with fluids and medications and cardiopulmonary resuscitation was performed for 60 minutes, the patient died.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Suchi Saria, PhD

Emerging Safety Issues in Artificial Intelligence, July 2019

Dr. Saria is the John C. Malone Assistant Professor of computer science, statistics, and health policy at Johns Hopkins University. Her research focuses on developing next generation diagnostic, surveillance, and treatment planning tools to reduce adverse events and individualize health care for complex diseases. We spoke with her about artificial intelligence in health care.


Emerging Safety Issues in Artificial Intelligence

Emerging Safety Issues in Artificial Intelligence, July 2019

Robert Challen, MA, MBBS

This piece explores various practical and philosophical issues that could shape the adoption of machine learning and artificial intelligence systems in medicine.

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Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

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Did You Know?

Frequent reasons for high dose-range alert overrides.


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Upcoming & Noteworthy

Promoting Professionalism: Addressing Behaviors That Undermine a Culture of Safety.

Vanderbilt Center for Patient and Professional Advocacy. August 2–3, 2019, Hilton San Diego Bayfront Hotel, San Diego, CA.

AHRQ Safety Program for Improving Antibiotic Use.

Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, University of Chicago.

View Upcoming Events

Most Viewed


Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.


Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.

White R, Cassano-Piché A, Fields A, Cheng R, Easty A. J Oncol Pharm Pract. 2014;20:40-46.


Dirty surgical tools put patients at risk.

Snyderman N. NBC News. February 22, 2012.