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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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May 1, 2024 Weekly Issue

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

Study
Marsh KM, Turrentine FE, Jin R, et al. J Am Coll Surg. 2024;238:874-879.
Knowing when judgment errors are more likely to occur can increase surgeons' awareness before, during, and after procedures. This study examined the records of 131 patients with 30-day morbidity or mortality to identify any errors in judgment that may have contributed to harm. Examples of errors in judgment included inappropriate operation, premature discharge, and premature removal of drain. Most errors...
Study
McMullan RD, Churruca K, Hibbert P, et al. Int J Qual Health Care. 2024;36:mzae030.
Unprofessional behavior negatively impacts teamwork, safety culture, and patient safety. This study analyzed 1,310 reports of unprofessional behavior across eight Australian hospitals between 2017-2020. The researchers found that three in ten reports indicated a risk to patient safety, such as interruptions, poor handover communication, and a lack of adherence to hospital policy or protocol.
Study
Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2024;Epub Mar 18.
Patient safety in ambulatory care settings is receiving increasing attention. This study evaluated an error management and safety climate intervention implemented across 184 ambulatory practices in Germany. The intervention included email newsletters on error management, e-learning modules to improve team engagement, and interdisciplinary workshops to discuss critical incidents. Survey feedback...
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Training and Education

Update Date: April 10, 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.

Eric Signoff, MD, Noelle Boctor, MD, and David K. Barnes, MD, FACE | April 10, 2024

A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech,... Read More

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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.