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AHRQ: Agency for Healthcare Research and Quality
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Patient Safety Network

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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Culture of Safety
Psychological and Social Complications
Medication Errors/Preventable Adverse Drug Events
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Discontinuities, Gaps, and Hand-Off Problems

The PSNet Collection

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RESOURCES
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WEBM&Ms
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June 5, 2024 Weekly Issue

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

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Study
Large language models for preventing medication direction errors in online pharmacies.
Pais C, Liu J, Voigt R, et al. Nat Med. 2024;Epub Apr 25.
Large language models (LLMs) are artificial intelligence (AI) based tools which are increasingly used in healthcare to improve clinical decision-making and patient safety. This article describes the MEDIC (medication direction copilot) system, which uses LMMs to reduce prescribing errors by improving medication direction-related communication. The researchers tested MEDIC within an existing pharmacy...
Commentary
Strengthening the use of artificial intelligence within healthcare delivery organizations: balancing regulatory compliance and patient safety.
Sendak MP, Liu VX, Beecy A, et al. J Am Med Inform Assoc. 2024;Epub May 20.
In 2022, the Food and Drug Administration (FDA) released new guidance which impacts how artificial intelligence-based clinical decision support (CDS) tools are reviewed and approved. This article explores the impact of these changes on CDS tools for sepsis care and how healthcare organizations can ensure safe, equitable use of CDS tools.
Book/Report
WHO Global Report on Patient Safety.

Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.

Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the seven objectives of the Global Patient Safety Action Plan 2021–2030 to examine the impact of unsafe care worldwide and the status of plan objective implementation in the six regions of World Health Organization (WHO) member states. It shares implementation successes and suggests areas of continued...
Study
Improving communication of diagnostic uncertainty to families of hospitalized children.
Young EE, Kane J, Timmons K, et al. Diagnosis (Berl). 2024;11:186-191.
Diagnostic uncertainty can be difficult to communicate without harming patient trust. This qualitative study examined deterrents to effective sharing of clinician uncertainty with caregivers of children whose diagnosis has yet to be determined. Challenges to these conversations include lack of time, language discordance, and lack of clarity around the uncertainty concept. The diagnostic pause and visual...

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Training and Education

Update Date: May 29, 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.

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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.

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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.

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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.
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