Browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nursing or medical specialty, featured in the resources.
Latest by Clinical Areas
Australian and New Zealand Tripartite Anaesthetic Data Committee.
Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves as a secure mechanism for submitting incident reports to a centralized... Read More
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.
Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who... Read More
ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.
Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent... Read More
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.
Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines... Read More
All Clinical Areas (1049)
A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.
Irving, TX: American College of Emergency Physicians; 2023.
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily.
Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.
A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.