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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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October 30, 2024 Weekly Issue

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

Study
Andrikyan W, Sametinger SM, Kosfeld F, et al. BMJ Qual Saf. 2024;Epub Oct 1.
Patients frequently use the internet, and now chatbots, to learn more about their health, symptoms, or medications. This study queried Microsoft's Bing chatbot, Copilot, about the 50 most frequently prescribed and over-the-counter medications. Drug.com's patient information was used for the reference database. Mean completeness was 76.7%, and mean accuracy was 88.7%. Experts evaluated a subset of 20...
Study
Browning S, Raleigh RA, Hattingh HL. Int J Clin Pharm. 2024;Epub Sep 30.
Transitions of care present challenges, such as loss of information or misunderstandings, that can negatively impact patient safety. This study explored how residential aged care facilities (RACF) manage medications when residents enter the facility from a hospital. The authors state that a resident discharged from the hospital to RACF ideally receives a supply of new or changed medications, a hard copy...
Study
Tsamasiotis C, Fiard G, Bouzat P, et al. Risk Manag Healthc Policy. 2024;17:1847-1858.
Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs) are two strategies to support individual and organizational learning from adverse events. This study, conducted at one French hospital, examined whether MMCs and EFCs improve patient safety culture among healthcare professionals. Findings suggest that participation in MMCs and EFCs improves certain aspects of safety...
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Training and Education

Update Date: October 30, 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.

Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN | October 30, 2024

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... Read More

Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

Upcoming Events

United States Meeting/Conference

Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.

Improvement Resources
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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.