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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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March 27, 2024 Weekly Issue

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

Study
Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion. 2024;Epub Mar 12.
Blood transfusion errors, while rare, can be severe and potentially fatal. This study used eight years of transfusion-related errors reported to the National Healthcare Safety Network (NHSN) Hemovigilance Module to quantify errors, adverse events, and blood wastage. Most reported errors were near misses and occurred during sample collection, sample handling, and product administration. Error reporting...
Study
Crozier N, Robinson E, Murtagh NC, et al. Hosp Pharm. 2024;59:210-216.
The Institute for Safe Medication Practices (ISMP) hierarchy of effectiveness of risk-reduction strategies ranks interventions from the least to most effective. Using 665 pharmacy-related medication safety reports at one hospital, researchers evaluated the actionability of the reports on the ISMP hierarchy. Three-quarters of the reports were only actionable at the least effective levels (e.g.,...
Study
Dellve L, Skagert K. Safety Sci. 2024;174:106488.
Rates of transmission of COVID-19 were high in nursing homes for both residents and staff with wide variation in implementing infection control measures. This study describes the gaps between infection control work-as-imagined and work-as-done in nursing homes and home health before and during the pandemic. Gaps included instructions for personal protective equipment created for hospitals that were not...
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Training and Education

Update Date: March 27, 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.

Michelle Hamline, MD, PhD, MAS and Ulfat Shaikh, MD, MPH | March 27, 2024

A five-year-old girl presented to the emergency department (ED) with symptoms of an upper respiratory tract infection. A viral swab was negative for SARS... Read More

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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

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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.