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March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
This Week’s Featured Articles
Alber DA, Yang Z, Alyakin A, et al. Nat Med. 2025;31(2):618-626.
To produce safe, accurate output, large language models (LLMs) must be trained on accurate information. In this study, researchers simulated a data-poisoning attack by implanting false medical information into a popular LLM training dataset. Results show that even a small amount of medical misinformation in the training dataset can result in harmful models that could compromise patient safety.
Bender JA, Thiyagarajan S, Morrish W, et al. J Patient Saf. 2025;21(2):69-81.
Miscommunication is a major contributor to adverse events. This article describes the development of a framework to classify communication errors that contributed to a patient safety incident. Nine types of communication errors were identified. Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication errors.
Mills PD, Tomolo A, Yackel EE. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20.
Health care is increasingly being provided remotely through telephone, video calls, and remote monitoring. Information on the prevalence and characterization of adverse events associated with telehealth is paramount to improving safety. This study analyzed 145 safety incidents related to telehealth at the VHA. The largest category was delays in care, and 90% of incidents resulted in no harm. Just over one-third were associated with the telehealth platform itself.
Milanesi M, Fiorito R, Caloccia L, et al. BMJ Open Qual. 2025;14(1):e003012.
Integrated care pathways (ICPs) are patient-centered and multidisciplinary. This article describes the development of an audit plan using Tracer methodologies to audit six oncology ICPs at a comprehensive cancer center. This methodology ensured the audit was patient-centered and focused on the patient's journey through several departments and facilities.
Mahajan P, White E, Shaw KN, et al. Acad Emerg Med. 2025;Epub Jan 15.
Electronic triggers and trigger tools are important methods of identifying and studying adverse events, such as missed opportunities for improving diagnosis (MOID). Using three triggers and the Revised Safer Dx Instrument, this study uncovered the frequency, type, causative factors, and severity of diagnostic errors in pediatric emergency departments. The overall frequency of MOID was 2.6% for the entire cohort, the majority of which resulted in patient harm.
Shieu B, Lee Y-W, Epps F, et al. J Gerontol Nurs. 2025;51(3):38-43.
Long-term care residents are at increased risk for experiencing medication administration errors. Using semi-structured phone interviews with 12 nurses, this qualitative study identified several important factors for improving medication safety in nursing home settings, including user-friendly charting systems, improved nurse-to-patient ratios, and customized medication administration interfaces.
Alber DA, Yang Z, Alyakin A, et al. Nat Med. 2025;31(2):618-626.
To produce safe, accurate output, large language models (LLMs) must be trained on accurate information. In this study, researchers simulated a data-poisoning attack by implanting false medical information into a popular LLM training dataset. Results show that even a small amount of medical misinformation in the training dataset can result in harmful models that could compromise patient safety.
Prothero MM, Sorhus M, Huefner K. J Nurs Adm. 2024;54(12):664-669.
Nursing leadership plays an important role in establishing a culture of safety. Findings from this cross-sectional survey with 255 nurse leaders highlight the important role of authentic leadership in fostering psychological safety and supporting nurses after serious medical errors. Survey respondents also endorsed the importance of formal support programs, including peer support, education, error analysis, and just culture.
Bender JA, Thiyagarajan S, Morrish W, et al. J Patient Saf. 2025;21(2):69-81.
Miscommunication is a major contributor to adverse events. This article describes the development of a framework to classify communication errors that contributed to a patient safety incident. Nine types of communication errors were identified. Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication errors.
Martins NRS, Martinez EZ, Simões CM, et al. Int J Qual Health Care. 2025;37(1):mzae114.
Poor handoff communication between teams can hinder safe patient care. This article describes the use of a risk management approach to improve handoffs from the operating room to intensive care. Frontline providers participated in a failure mode effects analysis (FMEA) to identify process failures, causes, and consequences related to handoffs. Participants reported that this approach helped them understand the handoff process beyond their individual roles.
Black GB, Nicholson BD, Moreland J-A, et al. BMJ Qual Saf. 2025;Epub Jan 29.
Patients presenting with non-specific symptoms (NSSs) suggestive of cancer may experience diagnostic delays. In this study with four National Health Service (NHS) NSS cancer pathways teams, researchers identified distinct functions of the team, clustered in pre-testing assessment and information gathering and post-testing interpretation and management. There was wide variation between the sites in referral processing, patient coordination, team communication, and follow up.
Morreim EH. Hous J Health Law Policy. 2025;24:127-165.
Artificial intelligence (AI) systems effect decision-making using a variety of clinical and managerial healthcare data sets. This article explores the potential weaknesses in large administrative databases – weaknesses inherent in data submitted to, and recorded by, humans – which can undermine the accuracy and effectiveness of AI generated information.
Aunger J, Maben J, Westbrook JI. Expert Rev Pharmacoecon Outcomes Res. 2025;Epub Jan 30.
Disruptive and unprofessional behavior can impact patient safety. This article highlights the effect that unprofessional behavior, including more subtle forms such as incivility and rudeness, has on patient safety, patient experience, and teamwork.
Rochford A. Future Healthc J. 2024;11(4):100205.
Medication errors and adverse drug events (ADEs) impact a significant number of patients every year. This article describes ongoing challenges (e.g., workforce limitations, polypharmacy) faced by safe prescribing and medication administration practices. The authors also highlight best practices and emerging approaches (such as artificial intelligence) that can advance medication and prescribing safety.
Mills PD, Tomolo A, Yackel EE. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20.
Health care is increasingly being provided remotely through telephone, video calls, and remote monitoring. Information on the prevalence and characterization of adverse events associated with telehealth is paramount to improving safety. This study analyzed 145 safety incidents related to telehealth at the VHA. The largest category was delays in care, and 90% of incidents resulted in no harm. Just over one-third were associated with the telehealth platform itself.
Perry K, Jones S, Stumpff JC, et al. J Hosp Med. 2024;Epub Nov 11.
Production pressure and decision fatigue can pose patient safety risks. This scoping review explored how decision fatigue impacts decision-making in inpatient settings. The scoping review, which included 16 studies (primarily focused on emergency and intensive care settings), reported inconsistent findings and did not robustly address the role of clinician, patient, or work factors on decision fatigue.
No results.
Andrew C, Fitzsimons M. APSF Newsletter. 2025;40(1):24-26.
Moving patients from one part of the hospital to another introduces clinical, communication and environmental risks that can reduce safety. This article discusses factors that contribute to patient safety events during intrahospital patient transport and presents a checklist as one mitigation strategy.
Multi-use Website
Patient Safety Authority.
Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event reports supports the spread of good ideas by generating interest in their application to drive patient safety improvement.
This Month’s WebM&Ms
WebM&M Cases
Andrew P.J. Olson, MD |
This pair of cases describes patients misdiagnosed and treated for migraines before being diagnosed with life-threatening conditions: encephalitis and cancer. The commentary discusses the challenges involved when diagnosing patients presenting with headache and a framework consisting of three key factors (diagnostic pitfalls, red flags, and “don’t miss” diagnoses) to consider in diagnostically challenging situations.
WebM&M Cases
Kristine Markham, PharmD, BCPPS and Maki Usui, PharmD, BCPPS, and Cady Smith BA |
Following an uncomplicated urologic surgery for hypospadias repair, a previously healthy 2-year-old boy was discharged with a 5-day course of hydrocodone-acetaminophen 7.5-325 mg/15 mL solution. The child was brought to the emergency department due to inconsolable crying. The ED workup was unremarkable, and he was sent home with a 4.6 day supply of oxycodone 1 mg/mL. Four days later, he became apneic, cyanotic, and unresponsive at home. Emergency first responders were called to the scene and the patient’s cardiac rhythm was determined to be pulseless electrical activity. They began cardiopulmonary resuscitation and administered naloxone and two doses of epinephrine. Upon arrival at the ED, continued resuscitation was unsuccessful, and the child was declared deceased. Inadvertent dose stacking and opioid polypharmacy may have contributed to this patient’s death.
WebM&M Cases
Spotlight Case
Samantha Brown, MD, Garth Utter, MD, MSc, and David K. Barnes, MD |
A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to another ED with similar symptoms and was diagnosed with a small bowel obstruction caused by adhesions from a ventral hernia. He underwent surgery but died three days later from multi-organ failure and sepsis caused by necrotic bowel and peritonitis. The commentary describes the appropriate evaluation for acute abdominal pain, the importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive biases in the diagnostic process.
This Month’s Perspectives
Perspectives on Safety
Edwin Boudreaux, PhD; Bryan Gale, MA; Sarah Mossburg, Phd |
Edwin Boudreaux, PhD, is a Professor of Emergency Medicine, Psychiatry, and Quantitative Health Sciences and the Vice Chair of Research for the Department of Emergency Medicine at the University of Massachusetts Chan Medical School.
Perspectives on Safety
Edwin Boudreaux, PhD; Bryan Gale, MA; Sarah Mossburg, PhD |
This piece discusses the role that healthcare providers and organizations can play in suicide prevention, including identifying suicide risk in patients and responding effectively.
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