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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.

PSNet Weekly Update

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

Latest WebM&M Issue

Expert analysis of medical errors.

WebM&M Cases
"Do You Want Everything Done?": Clarifying Code Status
Spotlight Case
Karl Steinberg, MD, CMD, HMDC and Thaddeus Mason Pope, JD, PhD ,  
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
The Need to Eat
Adrianne M Widaman, PhD, RD ,  
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
A Mistaken Dose of Naloxone 
Erika Cutler, PharmD, and Delani Gunawardena, MD ,  
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.

Latest Perspective

Expert viewpoints on current themes in patient safety.
Perspectives on Safety
Cultural Competence and Patient Safety
This piece describes cultural competence in the context of patient safety and highlights several approaches and projects that may help to improve cultural competence.
Perspectives on Safety
Cultural Competence and Patient Safety: Interview with Cindy Brach

Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of the HHS Health Literacy Workgroup. We spoke with her about the role of cultural competence in patient safety.

Ms. Brach has no conflict of interest to disclose.

View more information.

Patient Safety Primers

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

Upcoming & Noteworthy

Upcoming Meeting/Conference
The International Forum on Quality and Safety in Healthcare.
Institute for Healthcare Improvement and British Medical Journal. The International Forum on Quality and Safety in Healthcare. April 28-30, 2020, Bella Center Copenhagen, Copenhagen, Denmark.

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