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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 29, 2024 Weekly Issue

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

Study
Brashear J, Mize R, Laposata M, et al. Diagnosis (Berl). 2024;11:132-135.
Diagnostic management teams (DMT), which are comprised of experts in specialized fields, review patient cases and produce reports with diagnostic interpretations and recommendations for future testing or treatments. This pre/post study evaluates the effectiveness of a coagulation DMT at one hospital. Cases reviewed by the DMT were twice as likely to have a diagnostic conclusion (i.e., ruled in or ruled...
Study
Evans C, Da’Costa A. Emerg Nurse. 2024;Epub Apr 30.
Delayed handovers from emergency medical services (EMS) to the emergency department (ED) can significantly increase the risk of medical complications. This article describes a two-phase quality improvement project to decrease overall handover times as well the percentage of handovers occurring more than 60 minutes after arrival. Strategies included creation of a designated area for patients awaiting...
Review
Fentie AM, Huluka SA, Gebremariam GT, et al. Res Social Adm Pharm. 2024;20:487-497.
Oncology medications are high-risk due to complexity of patient care and patient polypharmacy. This review and meta-analysis highlights the impact of randomized control studies employing pharmacist-led interventions in oncology. Despite the heterogeneity of the included studies, pharmacist interventions can reduce medication errors in oncology. More research is required in low- and middle-income...
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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.

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

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.