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Classics and Emerging Classics

To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient safety field. These items have the potential to impact how providers approach care practice and are regularly referenced in the literature. More information on the selection process.

 

The “Emerging Classics” designation identifies those resources that may not have met the level of a “Classic” yet due to limited citation in the published literature or in the level of impact/contribution to the environment, but these are resources which our patient safety subject matter experts believe have the potential to drive change in the field.

Popular Classics

Huang SS, Septimus E, Kleinman K, et al. N Engl J Med. 2013;368.

Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This pragmatic,... Read More

All Classics and Emerging Classics (867)

1 - 20 of 52 Results
O'Sullivan ED, Schofield SJ. J R Coll Physicians Edinb. 2018;48:225-232.
Cognitive biases can lead to unnecessary treatment and delays in diagnosis. This commentary reviews examples of bias that commonly occur in medical practice and describes debiasing tactics to help improve decision-making.
Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.
Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.
Yu K-H, Kohane IS. BMJ Qual Saf. 2019;28:238-241.
Use of artificial intelligence (AI) and computer algorithms as tools to improve diagnosis have both risks and benefits. This commentary explores challenges to implementing AI systems at the front line of care in a safe manner and identifies weaknesses of advanced computing systems that influence their reliability.
Murphy DR, Meyer AN, Sittig DF, et al. BMJ Qual Saf. 2019;28:151-159.
Identifying and measuring diagnostic error remains an ongoing challenge. Trigger tools are frequently used in health care to detect adverse events. Researchers describe the Safer Dx Trigger Tools Framework as it applies to the development and implementation of electronic trigger tools that use electronic health record data to detect and measure diagnostic error. The authors suggest that by identifying possible diagnostic errors, these tools will help elucidate contributing factors and opportunities for improvement. They also suggest that, if used prospectively, such tools might enable clinicians to take preventive action. However, to design and implement these electronic trigger tools successfully, health systems will need to invest in the appropriate staff and resources. A past PSNet perspective discussed ongoing challenges associated with diagnostic error.
Croskerry P. Med Teach. 2018;40:803-808.
Clinical reasoning is a complex process that can be influenced by numerous factors. This commentary reviews major factors that affect clinical reasoning such as teamwork, decision-maker characteristics, and environmental conditions. The author suggests that an adaptive rather than linear decision-making approach would support reasoning improvements to reduce diagnostic error.
Schiff GD, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
Gillespie A, Reader TW. Milbank Q. 2018;96:530-567.
Patient voices provide crucial insight into health care safety hazards. Researchers classified 1110 patient complaints submitted to England's National Health Service to identify stages of care where harm occurred. The most common cause of major or catastrophic harm was diagnostic error.
Kale MS, Korenstein D. BMJ. 2018;362:k2820.
Overdiagnosis has emerged as a quality and safety concern due to its potential to result in financial and emotional harm for patients and their families. This review discusses factors that contribute to overdiagnosis in primary care including financial incentives and innovations in diagnostic technologies. The authors recommend increasing awareness about the negative consequences of unneeded screenings, clarifying the definition of overdiagnosis, and adjusting cultural expectations for testing and treatment as avenues for improvement.
Millenson ML, Baldwin JL, Zipperer L, et al. Diagnosis (Berl). 2018;5:95-105.
Recently, several mobile health care applications have been developed and marketed directly to nonclinician consumers. Researchers reviewed the literature regarding direct-to-consumer diagnostic applications. They found wide variation in the safety of these applications and suggest that further research is needed to thoroughly assess their effectiveness.
Young M, Thomas A, Lubarsky S, et al. Acad Med. 2018;93:990-995.
Enhancing clinical reasoning skill is emerging as a strategy to reduce diagnostic error. This review spotlights the need for a uniform definition of clinical reasoning and a robust literature base to augment efforts to improve reasoning and decision making. The authors suggest these refinements will identify cognitive biases and other contextual influences on clinical reasoning and improve education and professional development.
Clark BW, Derakhshan A, Desai S. Med Clin North Am. 2018;102:453-464.
Diagnostic errors have garnered increasing attention as a contributor to patient harm. This review explores reasons for underrecognition of diagnostic errors, including cognitive biases and large-scale system weaknesses. The authors suggest emphasis on education to enhance clinical knowledge, physical examination practice, and medical history-taking skills to improve diagnosis.
Anderson AM, Matsumoto M, Saul MI, et al. JAMA Dermatol. 2018;154:569-573.
Diagnostic errors among physician extenders are understudied, especially in subspecialty settings. In this study, physician assistants working in dermatology clinics performed more biopsies and diagnosed fewer skin cancers and melanoma than board-certified dermatologists. The authors were unable to assess how often either clinician type missed diagnoses of skin cancer.
Amjad H, Roth DL, Sheehan OC, et al. J Gen Intern Med. 2018;33:1131-1138.
This observation study found that patients who met criteria for dementia using objective assessments often lacked a formal dementia diagnosis, even when they regularly received medical care. Many patients who were diagnosed with dementia were not aware of their diagnosis. These results indicate the need to improve both diagnosis of dementia and communication regarding dementia diagnosis.
Liberman AL, Newman-Toker DE. BMJ Qual Saf. 2018;27:557-566.
Patient safety measurement remains challenging. This article describes a framework to address gaps in measuring diagnostic error. The authors propose utilizing big data to develop diagnostic performance dashboards and benchmarking tools that support proactive learning and improvement strategies.
Olson APJ, Graber ML, Singh H. J Gen Intern Med. 2018;33:1187-1191.
Research is increasingly focusing on diagnostic errors and strategies to reduce them. The challenges of measuring diagnostic difficulties has hindered progress. This commentary outlines a conceptual approach to identifying "undesirable diagnostic events." The authors propose developing a list of clinical contexts and specific diseases prone to diagnostic error. Candidate conditions should be diagnosable in routine practice with a clear reference standard and defined diagnostic process. They also contend that measures should be constructed for relatively common conditions that are often misdiagnosed and for which delayed diagnosis could lead to harm, such as delayed cancer diagnosis. The authors propose designing and testing diagnosis measures based on this framework. A previous PSNet perspective by the senior author, Hardeep Singh, discussed momentum in the field of diagnostic error over the past several years.
Bhise V, Meyer AND, Menon S, et al. Int J Qual Health Care. 2018;30:2-8.
Reducing diagnostic error is an area of increasing focus within patient safety. However, little is known about how patients perceive physician communication regarding diagnostic uncertainty. In this study, participants (parents of pediatric patients) were assigned to read one of three clinical vignettes each describing a different approach to a physician communicating diagnostic uncertainty; they were then asked to answer a questionnaire. Researchers found that explicit expression of diagnostic uncertainty by a physician was associated with negative perceptions of physician competence as well as diminished trust and satisfaction with care, whereas more implicit language was not. A past Annual Perspective highlighted some of the challenges associated with diagnostic error.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Bhise V, Rajan SS, Sittig DF, et al. J Gen Intern Med. 2018;33:103-115.
Recognizing and measuring diagnostic error can be challenging, which hinders efforts to study and improve diagnosis. This systematic review of 123 studies sought to characterize diagnostic uncertainty. Despite the lack of an explicit definition in any study, researchers identified diagnostic uncertainty as a clinician perception that affects diagnostic evaluation and changes over time. Strategies to measure diagnostic uncertainty included assessing clinician perceptions through survey or interview methods, examining the diagnostic evaluation through medical record review, or employing simulation with standardized cases or vignettes. The authors propose the following definition of diagnostic uncertainty: "subjective perception of an inability to provide an accurate explanation of the patient's health problem," paralleling the National Academy of Medicine's definition of diagnosis. A recent WebM&M commentary discussed how cognition influences diagnostic decision-making.
Washington, DC: National Quality Forum. September 19, 2017.
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and mitigating diagnostic error remains challenging. This National Quality Forum report describes the development of a framework to assist with measuring diagnostic quality and safety. The framework outlines 3 domains and 11 subdomains for measuring diagnostic quality and safety as well as 62 prioritized measure concepts. High-priority areas for measure development include timeliness of diagnosis, timely follow-up of test results, communication and handoffs, patient-reported diagnostic errors, and patient experience related to diagnostic care. The committee also identified several cross-cutting themes and makes recommendations for researchers seeking to develop measures to improve diagnostic safety. A PSNet perspective discussed challenges and opportunities regarding diagnostic error.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27:53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.