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.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Wong BM, Baum KD, Headrick LA, et al. Acad Med. 2020;95:59-68.
An international group of educational and health system leaders, educators, front-line clinicians, learners, and patients convened to create a list of actionable strategies that organizations can use to better integrate Quality Improvement Patient Safety (QIPS) education with clinical care. A framework and list of concrete examples describe how groups can get started.
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.
This direct observation study examined cognition among experienced clinicians in the setting of their recertification examination and found that when they changed answers, it was usually from an incorrect to a correct response. This suggests that further reflection enhances accuracy compared to intuitive response, consistent with work on metacognition to enhance diagnostic accuracy.
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
Chesluk BJ, Holmboe ES. Health Aff (Millwood). 2010;29:874-879.
After observing the daily workings of three internal medicine practices, investigators concluded that physicians and practice staff worked mainly in silos. The practices' ability to deliver patient-centered care was limited by the lack of true interdisciplinary teams.