psnet.ahrq.govPSNet Patient Safety Network

Sorry, you need to enable JavaScript to visit this website. An official website of the Department of Health & Human Services Search All AHRQ Sites Careers Contact Us Español FAQs Email Updates Provide Feedback | Submit a Case Login Register The PSNet Collection All Content Classics Perspectives Current Weekly Issue Past Weekly Issues Curated Libraries Clinical Areas Patient Safety 101 The Fundamentals Primers Topics Glossary Training and Education Overview Continuing Education WebM&M: Case Studies Training Catalog Submit a Case Improvement Resources Overview Innovations Toolkits Submit an Innovation About PSNet About Contact Editorial Team Technical Expert PanelBack to search The PSNet Collection All Content Classics Perspectives Current Weekly Issue Past Weekly Issues Curated Libraries Clinical Areas Patient Safety 101 The Fundamentals Primers Topics Glossary Training and Education Overview Continuing Education WebM&M: Case Studies Training Catalog Submit a Case Improvement Resources Overview Innovations Toolkits Submit an Innovation About PSNet About Contact Editorial Team Technical Expert Panel Promoting Patient Safety. Search Apply Advanced Search Search Tips 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 ). Browse the Collection Learn More About Patient Safety Browse by Clinical Areas Popular Searches Culture of Safety Medication Errors/Preventable Adverse Drug Events Psychological and Social Complications Discontinuities, Gaps, and Hand-Off Problems Communication between Providers The PSNet Collection - RESOURCES - PERSPECTIVES - WEBM&Ms - PRIMERS 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. View the Weekly Issue RSS Feed 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. Browse by Clinical Areas View All Clinical Areas Children’s Health Emergency Medicine Hospital Medicine Maternal and Women’s Health Nurse Care Pharmacy Primary Care Surgery Sign up for PSNet Issues today! Go to AHRQ site and subscribe 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 . View Training and Education Spotlight Case CE/MOC New Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Christian Bohringer, MBBS, Manuel Fierro, MD, and Sandhya Venugopal, MD | April 24, 2024 A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went... Read More Take the Quiz New Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. David K. Barnes, MD, FACEP, Sahej Deep Singh Randhawa, MD, and Ellen P. Fitzpatrick, MD | April 24, 2024 This pair of cases highlight the immediate and long-term consequences of delayed recognition of compartment syndrome,... Read More New Verbal Orders and Medication Overrides: A Dangerous Combination Catherine Mueller, PharmD, CPPS, Paul MacDowell, PharmD, BCPS, and James A. Bourgeois, OD, MD | April 24, 2024 A 26-year-old man presented to the emergency department (ED) with abdominal pain, displaying tachycardia and extreme agitation. Despite... Read More New Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? Ron Ordona, DNP, FNP-BC, GS-C, WCC and Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN | April 24, 2024 An elderly patient residing in a group care home, requiring assistance with all activities and having a... Read More Misplaced Nasogastric Tube Resulting in Aspiration Anita Singh, MD and Cecilia Huang, MD | April 10, 2024 An 82-year-old woman presented to the emergency department for evaluation of altered mental status” after falling down 5 step-stairs at home. She had... Read More Spotlight Case CE/MOC 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 Take the Quiz 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. Submit Your Case Upcoming Events View All Upcoming Events International Meeting/Conference Certified Professional in Patient Safety Review Course. Institute for Healthcare Improvement. June 5-6 2024, 12:00-4:00 PM (eastern). International Meeting/Conference TeamSTEPPS Master Training Course. Armstrong Institute for Patient Safety and Quality. June 11 and 13, 2024. United States Meeting/Conference CUSP Implementation Training. Armstrong Institute for Patient Safety and Quality. Improvement Resources Innovations The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety. Toolkits Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. Latest...