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March 5, 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
Boisvert S, Nelson M, Ross J. J Patient Saf. 2025;21(2):111-117.
Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care. In this analysis of closed malpractice claims, anti-infectants, narcotics, and anticoagulants were identified in nearly half of the claims. Clinical judgment and communication were the most common contributing factors.
Hose B-Z, Handley JL, Biro J, et al. BMJ Qual Saf. 2025;34(2):130-132.
Information on the prevalence of errors in artificial intelligence applications and their impact on the healthcare system provides important guidance on development, implementation, and use. This article describes the development of a classification system for two popular uses of AI in health care: patient-facing large language models (LLM) and ambient digital scribes (ADS). Errors were prevalent in both types, with errors of omission being the most common. Although most errors in the LLM were categorized as having low clinical significance, 25% were categorized as high clinical significance (e.g., omissions of urgent guidance for conditions such as heart attack symptoms).
Awtry J, Skinner S, Polazzi S, et al. JAMA Surg. 2025;Epub Jan 15.
Stress among surgeons is common and may be associated with surgical errors. This study tracked surgeons' stress using body-worn sensors during the first 5 minutes of surgery to explore the association between stress and postoperative complications. Interestingly, increased stress during the first 5 minutes of surgery was associated with reduced major surgical complications. There was no association with intensive care unit stay or mortality.
Boisvert S, Nelson M, Ross J. J Patient Saf. 2025;21(2):111-117.
Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care. In this analysis of closed malpractice claims, anti-infectants, narcotics, and anticoagulants were identified in nearly half of the claims. Clinical judgment and communication were the most common contributing factors.
Awtry J, Skinner S, Polazzi S, et al. JAMA Surg. 2025;Epub Jan 15.
Stress among surgeons is common and may be associated with surgical errors. This study tracked surgeons' stress using body-worn sensors during the first 5 minutes of surgery to explore the association between stress and postoperative complications. Interestingly, increased stress during the first 5 minutes of surgery was associated with reduced major surgical complications. There was no association with intensive care unit stay or mortality.
Hose B-Z, Handley JL, Biro J, et al. BMJ Qual Saf. 2025;34(2):130-132.
Information on the prevalence of errors in artificial intelligence applications and their impact on the healthcare system provides important guidance on development, implementation, and use. This article describes the development of a classification system for two popular uses of AI in health care: patient-facing large language models (LLM) and ambient digital scribes (ADS). Errors were prevalent in both types, with errors of omission being the most common. Although most errors in the LLM were categorized as having low clinical significance, 25% were categorized as high clinical significance (e.g., omissions of urgent guidance for conditions such as heart attack symptoms).
Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Safety Sci. 2025;184:106728.
Incident reporting systems are considered an essential tool for learning from patient safety events, but concerns have been raised about their limitations. This ethnographic study, conducted at one Dutch neurology/neurosurgery ward, found that nurses struggle to define “report-worthy” events and question whether actions stemming from incident reports ultimately benefit patient safety.
Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Jt Comm J Qual Patient Saf. 2025;51(2):144-158.
The use of simulation and debriefing is an effective strategy for learning. This article describes the development of Simulation-Debriefing Enhanced Needs Assessment (SDENA) to identify behavioral barriers and enablers for implementing healthcare-acquired condition improvement projects at the unit level. Following the simulation, most participants responded that SDENA would be feasible in their unit. After 3-6 months, 8.8% had implemented SDENA.
Hsiao L-H, Kopar PK. J Am Coll Surg. 2025;240(2):221-228.
Surgical errors have the potential to result in severe negative consequences for patients, thereby increasing the likelihood that surgical staff making an error will experience significant emotional and psychological distress known as second victim syndrome (SVS). In this study, surgeons and surgical residents reported that experiencing SVS is inevitable. Healthcare institutions, therefore, have a moral imperative to support providers following adverse surgical outcomes. Additionally, discussion and review of adverse events must remain confidential, privileged, and inadmissible in possible legal actions.
Hooftman J, Zwaan L, Sikkens JJ, et al. Diagnosis (Berl). 2025;34(2):130-132.
Longitudinal trends in adverse events (AEs) can provide insights into incidence, preventability, and causes not easily found in cross-sectional studies. Data from four studies that included 19-20 hospitals were analyzed to estimate the occurrence of diagnostic adverse events (DAEs) from 2008 to 2019. DAEs decreased from 2008 to 2012, at which point they stabilized. Rates were similar for other AEs, although DAEs were considered more preventable and were associated with more preventable deaths.
Skinner SM, Kippen E, Rolnik DL, et al. BMC Pregnancy Childbirth. 2025;25(1):47.
Labor and delivery is a high-risk care setting that requires teamwork among different clinical areas and providers. This qualitative study with maternity care providers in Australia identified significant communication concerns, particularly among midwifery and pediatric staff. The study highlights key areas for improving teamwork, including communication quality, leadership dynamics, and standardized clinical practice.
Rowland P, Lan MF, Wan C, et al. J Health Organ Manag. 2025;Epub Jan 15.
Patient safety event reports and investigations offer unique opportunities for individual and organizational learning. In this study, researchers interviewed staff and physicians at one Canadian hospital about their experiences with incident investigations and follow-up processes. Participants noted that issues such as privacy policies and a focus on severe outcomes can hamper learning opportunities.
Taylor RA, Sangal RB, Smith ME, et al. Acad Emerg Med. 2024;Epub Dec 15.
Diagnostic errors remain a persistent patient safety concern, especially in high-pressure environments like the emergency department (ED). This article summarizes the features of clinical decision-making in the ED and how artificial intelligence (AI)-enabled tools, such as clinical decision support (CDS) and triggers, can enhance evidence-based diagnosis and reduce cognitive overload.
Garratt S, Dowling A, Manias E. J Adv Nurs. 2025;81(2):621-640.
Adverse drug events (ADEs) are one of the most common adverse events in long-term care (LTC). This systematic review synthesizes staff, resident, and family perspectives on medication administration ADEs in LTC. Five themes were uncovered: staffing, the uncertain role of residents, medication-related decision-making, use of electronic medication administration records, and medication administration errors. Dose form modification, such as crushing tablets and adding them to food, was a common approach to ensure adherence. This activity calls into question resident autonomy to decline medications as well as safety for medications that should not be modified.
Cahill M, Cleary BJ, Cullinan S. BMC Health Serv Res. 2025;25(1):31.
Poor electronic health record (EHR) design can result in medication errors. This systematic review sought to evaluate what design features within EHRs can impact medication safety. Design elements fell into one or more of the following themes: searchability, automation, customization, data entry, workflow, user guidance, and interoperability.
No results.
(DeVita MA, ed.). Springer; 2025. ISBN 9783031679513.
Rapid response systems are a core strategy to ensure safe care for hospitalized patients should unexpected deterioration occur. This book supports the implementation and effective use of strategies that support effective rapid response programs. Topics include the importance of understanding failure to rescue, the patient’s role in care escalation, and systems thinking as a framework for examining rapid response system success.
Special or Theme Issue
Front Health Serv. 2024.
Patient and family engagement in care improvement can yield helpful insights that inform action. This evolving collection includes articles exploring topics such as the involvement of older adults in the diagnostic process and management of harm after safety incidents.
This Month’s WebM&Ms
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
Interview
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |
Timothy Vogus is the Brownlee O. Currey, Jr., Professor of Management at Vanderbilt University’s Owen Graduate School of Management. He is also a founding and continuing member of the Blue Ribbon Panel that developed Leapfrog Group's Hospital Safety Score.
Perspectives on Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD |
Dr. Lucy Savitz is a professor of health policy and management at the University of Pittsburgh School of Public Health. We spoke with her about learning systems and their impact on patient safety.
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