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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

A prescription for enhancing electronic prescribing safety.

Schiff G, Mirica MM, Dhavle AA, Galanter WL, Lambert B, Wright A. Health Aff (Millwood). 2018;37:1877-1883.

Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?

Al Mohajer M, Joiner KA, Nix DE. Acad Med. 2018;93:1827-1832.

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

Randall KH, Slovensky D, Weech-Maldonado R, Patrician PA, Sharek PJ. Jt Comm J Qual Patient Saf. 2018 Nov 21; [Epub ahead of print].

Improving electronic health record usability and safety requires transparency.

Ratwani RM, Hodgkins M, Bates DW. JAMA. 2018 Nov 29; [Epub ahead of print].

Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial.

Oner C, Fisher N, Atallah F, et al. Simul Healthc. 2018;13:404-412.

Patterns of disrespectful physician behavior at an academic medical center: implications for training, prevention, and remediation.

Hopkins J, Hedlin H, Weinacker A, Desai M. Acad Med. 2018;93:1679-1685.

Learning from tragedy: the Julia Berg story.

Graber ML, Berg D, Jerde W, Kibort P, Olson APJ, Parkash V. Diagnosis (Berl). 2018;5:257-266.

Newspaper/Magazine Article

Medicare cuts payments to nursing homes whose patients keep ending up in hospital.

Rau J. Kaiser Health News. December 3, 2018.


McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.

Press Release/Announcement

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

Washington, DC: Office of the National Coordinator for Health Information Technology; November 28, 2018.

Latest WebM&M Issue

Expert analysis of medical errors.

Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees

  • Spotlight Case
  • CE/MOC

Olle ten Cate, PhD, November 2018

An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.

Written Signout: It Only Works If You Use The Right One

Kheyandra Lewis, MD, and Glenn Rosenbluth, MD, November 2018

Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.

Inadequate Preanesthetic Evaluation, Airway Trouble

Jeanna Blitz, MD, November 2018

When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.

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Latest Perspectives

Expert viewpoints on current themes in patient safety.


In Conversation With… David Meltzer, MD, PhD

The Comprehensive Care Physician Model, November 2018

Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.


The Comprehensivist Model of Care: A Hospitalist's View

The Comprehensive Care Physician Model, November 2018

Robert Wachter, MD

This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.

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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?

Ways diagnostic uncertainty is directly expressed in primary visit notes. Table 1


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Upcoming & Noteworthy

CUSP Implementation Workshop.

Armstrong Institute for Patient Safety and Quality. January 8, 2019; Constellation Energy Building Conference Center, Baltimore, MD.

National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2018.

View Upcoming Events

Most Viewed


Medication reconciliation at hospital discharge: evaluating discrepancies.

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


Sponges, tools and more left inside Washington hospital patients.

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


Computerised provider order entry and residency education in an academic medical centre.

Wong B, Kuper A, Robinson N, et al. Med Educ. 2012;46:795-806.