New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors

Two new Web M&M (Morbidity & Mortality) Rounds on the Web case studies from AHRQ’s Patient Safety Network (PSNet) include expert analyses of medical errors submitted by PSNet users. In one case, an 18-year-old man with a history of untreated depression and suicide attempts did not receive a suicide risk assessment until he was found in a hotel room with a loaded gun. In another case, a 52-year-old breast cancer patient scheduled for a lumpectomy did not receive the necessary injection of radiotracer dye before being placed under general anesthesia. In addition, AHRQ’s Patient Safety Network (PSNet), which highlights journal publications, books, and tools related to patient safety, features a new set of articles including:

• Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study
• Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme
• Care quality, patient safety, and nurse outcomes at hospitals serving economically disadvantaged patients: a case for investment in nursing

Review additional new publications in PSNet’s current issue or access recent cases and commentaries in AHRQ’s WebM&M (Morbidity and Mortality Rounds on the Web).