Welcome to PSNet

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

PSNet Weekly Update

What's new in patient safety literature, news, & more.
Journal Article

Latest WebM&M Issue

Expert analysis of medical errors.

WebM&M Cases
Think Like a Surgeon
Zara Cooper, MD, MSc,  
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.
Getting the Diagnosis Both Right and Wrong
Commentary by Andrew P. Olson, MD,  
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspectives on Safety
Patient Safety and the Evolution of WebM&M and PSNet
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
In Conversation With… Shantanu Agrawal, MD, MPhil
Dr. Agrawal is president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.
View more information.

Patient Safety Primers

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

Upcoming & Noteworthy

United States Meeting/Conference
Patient Safety Certificate Program.
American Society for Healthcare Risk Management. October 11-12, 2019, Baltimore Convention Center, Baltimore MD.

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