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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

The fifth vital sign? Nurse worry predicts inpatient deterioration within 24 hours.

Romero-Brufau S, Gaines K, Nicolas CT, Johnson MG, Hickman J, Huddleston JM. JAMIA Open. 2019 Aug 28; [Epub ahead of print].

Effectiveness of double checking to reduce medication administration errors: a systematic review.

Koyama AK, Maddox CS, Li L, Bucknall T, Westbrook JI. BMJ Qual Saf. 2019 Aug 7; [Epub ahead of print].

Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.

Pinkney SJ, Fan M, Koczmara C, Trbovich PL. Crit Care Med. 2019;47:e597-e601.

Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot?

Ellis RJ, Schlick CJR, Feinglass J, et al. BMJ Qual Saf. 2019 Jul 31; [Epub ahead of print].

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies.

Farre A, Heath G, Shaw K, Bem D, Cummins C. BMJ Qual Saf. 2019 Jul 29; [Epub ahead of print].

Saving Patient Ryan—can advanced electronic medical records make patient care safer?

Hydari MZ, Telang R, Marella WM. Manage Sci. 2019;65:2041-2059.

Review of alternatives to root cause analysis: developing a robust system for incident report analysis.

Hagley G, Mills PD, Watts BV, Wu AW. BMJ Open Qual. 2019;8:e000646.

Special or Theme Issue

Emerging Concepts in Patient Safety.

Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.

Newspaper/Magazine Article

Lyme disease is baffling, even to experts, but new insights are at last accumulating.

O'Rourke M. The Atlantic. September 2019.

When is a doctor too old for the job?

Palmer J. Patient Saf Qual Healthc. August 29, 2019.


ACHE's Executive Learning Lab: Leading for Safety.

American College of Healthcare Executives. October 10–11, 2019; Cleveland Clinic, Cleveland, OH.

Latest WebM&M Issue

Expert analysis of medical errors.

A Femoral Sheath Fatality

  • Spotlight Case
  • CE/MOC

Hildy Schell-Chaple, RN, PhD, September 2019

After undergoing a scheduled percutaneous coronary intervention, a man with a femoral sheath still in place was admitted to the medical ward, where several beds had recently been converted to cardiac telemetry beds. Having limited experience with femoral sheaths, the nurse removed it but was unable to assess the patient every 15 minutes as required due to becoming busy with another patient. One hour later, the patient was unresponsive, a code was called, and he was transferred to the intensive care unit where he died several hours later.

Getting the Diagnosis Both Right and Wrong

Andrew P. Olson, MD, September 2019

A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed.

Think Like a Surgeon

Zara Cooper, MD, MSc, September 2019

A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… Shantanu Agrawal, MD, MPhil

Patient Safety at 20, September 2019

Dr. Agrawal is president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.


Patient Safety and the Evolution of WebM&M and PSNet

Patient Safety at 20, September 2019

Sumant Ranji, MD, and Robert M. Wachter, MD

This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.

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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?

Clinical effects of medication errors occurring in the community.


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Upcoming & Noteworthy

Addressing Diagnostic Error: A Top Source of Preventable Harm and Cost.

American College of Healthcare Executives and Society to Improve Diagnosis in Medicine. September 24, 2019, 12:00–1:30 PM (Eastern).

Patient Safety Learning Annual Conference 2019.

Patient Safety Learning. October 2, 2019; London, UK.

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Most Viewed


Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.


Resource-based view on safety culture's influence on hospital performance: the moderating role of electronic health record implementation.

Upadhyay S, Weech-Maldonado R, Lemak CH, Stephenson A, Mehta T, Smith DG. Health Care Manage Rev. 2018 Aug 28; [Epub ahead of print].


Sponges, tools and more left inside Washington hospital patients.

Ryan J. KUOW. National Public Radio. August 1, 2013.