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Promoting Patient Safety.

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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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November 6, 2024 Weekly Issue

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

Study
Lam A, Plombon S, Garber A, et al. Appl Clin Inform. 2024;15:733-742.
The failure of a provider to communicate the diagnosis to the patient is a diagnostic error. This communication includes not only telling the patient what their diagnosis is but also ensuring they understand it. In this study, hospitalized patients were asked if "the healthcare team told you the main reason you're in the hospital (your diagnosis) in a way you understand" and their level of confidence in...
Study
Manuel R, Barber A, Kern J, et al. Ped Qual Saf. 2024;9:e767.
Interprofessional communication and teamwork is critical to patient safety. First-year medical and nursing residents participated in team engagement sessions focused on collaboration and safety behaviors through socialization, team communication, and engagement skills. Sessions consisted of a pre-recorded scenario of a safety event resulting in a patient's death followed by a facilitated debrief....
Review
Ouanes K, Farhah N. J Med Syst. 2024;48:74.
Artificial intelligence-based clinical decision support systems (AI-CDSS) hold promise for improving patient outcomes. This review identified 26 articles on the effectiveness of AI-CDSS on patient outcomes. The content analysis revealed 4 themes: early detection and disease diagnosis, enhanced decision-making, medication errors, and clinicians' perspectives. Only 3 of the interventions, which were within...
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Training and Education

Update Date: October 30, 2024

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.

Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN | October 30, 2024

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... 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

United States Meeting/Conference

Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.

Improvement Resources
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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.