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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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April 24, 2024 Weekly Issue

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

Review
Bradford A, Meyer AND, Khan S, et al. BMJ Qual Saf. 2024;Epub Apr 4.
Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood, and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis...
Study
Forbes J, Arrieta A. BMJ Lead. 2024;Epub Apr 3.
Front-line workers (e.g., nurses and physicians) and leaders frequently perceive the safety culture in their organization differently. This study uses data from AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS) V.1.0 from 2008 - 2017 to compare leadership and front-line workers' perceptions of patient safety culture. With responses from 1,810 hospitals and more than 800,000 individuals identified...
Review
Slawomirski L, Hensher M, Campbell JL, et al. Health Policy. 2024;143:105051.
Pay-for-performance (P4P) policies and programs (such as the Hospital-Acquired Condition [HAC] Reduction Program) intend to incentivize high-quality care and reduce medical errors. This systematic review including 53 articles explored the impact of P4P on the incidence of adverse events in acute care settings. The researchers found that half of the included studies did not identify improvements in...
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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.

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

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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.

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Improvement Resources
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Innovations

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

Toolkit
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.