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PSNet highlights the latest patient safety literature, news, and expert commentary, including weekly updates, WebM&M, Patient Safety Primers, and more.

Journal Article

Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.

Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019 Mar 1; [Epub ahead of print].

Electronic patient identification for sample labeling reduces wrong blood in tube errors.

Kaufman RM, Dinh A, Cohn CS, et al; BEST Collaborative. Transfusion. 2019;59:972-980.

Assessing the use of Google Translate for Spanish and Chinese translations of emergency department discharge instructions.

Khoong EC, Steinbrook E, Brown C, Fernandez A. JAMA Intern Med. 2019 Feb 25; [Epub ahead of print].

Americans' growing exposure to clinician quality information: insights and implications.

Schlesinger MJ, Rybowski L, Shaller D, et al. Health Aff (Millwood). 2019;38:374-382.

Characterising ICU–ward handoffs at three academic medical centres: process and perceptions.

Santhosh L, Lyons PG, Rojas JC, et al. BMJ Qual Saf. 2019 Jan 12; [Epub ahead of print].

Essential activities for electronic health record safety: a qualitative study.

Ash JS, Singh H, Wright A, Chase D, Sittig DF. Health Informatics J. 2019 Mar 8; [Epub ahead of print].

The impact of mobile technology on teamwork and communication in hospitals: a systematic review.

Martin G, Khajuria A, Arora S, King D, Ashrafian H, Darzi A. J Am Med Inform Assoc. 2019;26:339-355.

Newspaper/Magazine Article

Could CDC guidelines be driving some opioid patients to suicide?

Dickson EJ. Rolling Stone. March 9, 2019.


Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.

Error and Uncertainty in Diagnostic Radiology.

Bruno MA. New York, NY: Oxford University Press; 2019. ISBN: 978-0190665395.

Press Release/Announcement

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

US Food and Drug Administration. March 8, 2019.

Latest WebM&M Issue

Expert analysis of medical errors.

Which Line: Ordering Provider or Proceduralist?

  • Spotlight Case
  • CE/MOC

C. Craig Blackmore, MD, MPH, March 2019

A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.

Premature Extubation

Rommel Sagana, MD, and Robert C. Hyzy, MD, March 2019

Following an elective carotid endarterectomy, an elderly woman was extubated in the operating room (OR) and brought to the recovery area. She soon developed respiratory distress necessitating urgent reintubation, which required multiple attempts. She was found to have an expanding neck hematoma, which was drained safely in the OR. Later that day after a half hour weaning trial, the respiratory therapist extubated the patient without checking for a cuff leak. Within 15 minutes, she developed acute shortness of breath and stridor, which rapidly progressed to hypoxemic respiratory failure. Urgent reintubation was difficult because her vocal cords were edematous.

Duplicate Insulin Order

Nicole M. Acquisto, PharmD, and Daniel J. Cobaugh, PharmD, March 2019

Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin. However, both the intern and the resident ordered 50 units of insulin, and the patient received both doses—causing his blood glucose level to dip into the 30s.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Susan Haas, MD, MSc

Health System Consolidation and Patient Safety, March 2019

Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health care system expansion. We spoke with her about the trend of health systems getting larger and more integrated, the risks to patient safety, and ways to mitigate these risks.


Building a Safety Program in a Vast Health Care Network

Health System Consolidation and Patient Safety, March 2019

Paul E. Phrampus, MD

This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.

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Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

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Did You Know?

Common types of medication errors occurring outside health care settings.


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Upcoming & Noteworthy

Patient Safety Certificate Program.

Armstrong Institute for Patient Safety and Quality. March 25–29, 2019; Armstrong Institute for Patient Safety and Quality, Baltimore, MD.

IHI Fellowship Program.

Institute for Healthcare Improvement

View Upcoming Events

Most Viewed


Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data.

Abel GA, Mendonca SC, McPhail S, Zhou Y, Elliss-Brookes L, Lyratzopoulos G. Br J Gen Pract. 2017;67:e377-e387.


Medication reconciliation at hospital discharge: evaluating discrepancies.

Wong JD, Bajcar JM, Wong GG, et al. Ann Pharmacother. 2008;42:1373-1379.


Evaluation and certification of computerized physician order entry systems.

Classen D, Avery AJ, Bates DW. J Am Med Inform Assoc. 2007;14:48-55.