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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 5 of 5 Results
Schiff G, Hasan O, Kim S, et al. Arch Intern Med. 2009;169:1881-1887.
Diagnostic errors are a known cause of preventable adverse events, and while safety prevention efforts have traditionally focused more in other areas, this may be the new frontier. This study analyzed 583 self-reported diagnostic errors and found that 69% were rated as moderate or major. The most common missed or delayed diagnoses were pulmonary embolism and drug reactions or overdose, with the errors occurring most frequently in the testing phase (eg, failure to order, report, and follow up on results). The authors developed a comprehensive taxonomy tool, Diagnostic Error Evaluation and Research (DEER), as a method to aggregate cases by diagnosis and error types, which assisted in identifying future prevention strategies. An invited commentary [see link below] by a leader in the patient safety field, Dr. Robert Wachter, discusses the importance of this study's findings while reflecting on the 10-year anniversary of the landmark IOM report. A past AHRQ WebM&M commentary and perspective also discussed diagnostic errors.
Berner ES, Graber ML, eds. Adv Health Sci Educ Theory Pract. 2009;14(suppl 1):1-112.
This supplement consists of 12 articles drawn from a 2008 conference on diagnostic error, covering topics such as medical problem solving, clinical decision making, diagnostic decision support systems, and educational approaches to reducing diagnostic errors.
Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250.
Clinical reasoning lies at the heart of formulating diagnoses and selecting treatments. The results of these medical decisions determine a substantial portion of the dollars spent on health care. Considering the fundamental importance of clinical reasoning, the topic has received surprisingly little systematic study. Even with the widespread interest in medical error and patient safety in recent years, diagnostic errors and other errors in clinical reasoning have received little attention. This classic collection of empiric studies on clinical reasoning in action thus remains highly relevant more than 25 years after its original publication. One finding of particular relevance for those interested in patient safety and quality improvement is that competence may be problem specific; thus, there is no generic approach to clinical problem solving that, when followed, ensures excellent, or even competent, performance in a variety of domains within a field. The authors also provide an excellent overview of theoretic models relevant to the study of clinical reasoning.