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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
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The PSNet Collection

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May 8, 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
Entangled in complexity: an ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs.
Hedqvist A‐T, Praetorius G, Ekstedt M, et al. J Adv Nurs. 2024;Epub Apr 20.
Transitions of care are a vulnerable time for all patients and especially older adults with complex care needs. Utilizing document review, observations, and interviews, this study describes how inconsistencies in timing and precision at the time of transition put patients at risk. Examples include early discharge from hospital due to crowding, insufficient assessment of activities of daily living, and...
Study
Comparative evaluation of LLMs in clinical oncology.
Rydzewski NR, Dinakaran D, Zhao SG, et al. NEJM AI. 2024;1:AIoa2300151.
Large language models (LLM) are being developed to improve diagnostic accuracy. This study compared five LLMs on their accuracy of oncology diagnoses. Accuracy ranged from no better than random chance to similar to resident physicians. Notably, all models exhibited poor performance on women-predominant malignancies, suggesting a bias in training materials. This highlights the importance of partnerships...
Review
Application of trigger tools for detecting adverse drug events in older people: a systematic review and meta-analysis.
Schiavo G, Forgerini M, Varallo FR, et al. Res Social Adm Pharm. . 2024;Epub Mar 22.
Adverse drug events (ADE) are common in older adults. This systematic review identified 12 trigger tools for detecting ADE in older adults. Trigger tools designed or adapted for the older adult population performed better than those designed for the general population. Most studies assessed performance using positive predictive value (PPV), but there was no consensus of what constitutes a good or poor...
Study
Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia.
Motamedi M, Degeling C, M. Carter S. BMC Health Serv Res. 2024;24:436.
Women patients experience medical gaslighting wherein clinicians, policy makers, or the public do not believe their lived experiences. This article details more than 400 accounts submitted by women who were harmed by transvaginal mesh, and how their harm was exacerbated by dismissals by their physicians and regulatory bodies.

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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.

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CE/MOC
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Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
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.

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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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