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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 - 6 of 6 Results
Sonis J, Pathman DE, Read S, et al. J Healthc Manag. 2022;67:192-205.
Lack of organizational support can inhibit safety culture and increase risk of burnout among healthcare workers. Researchers surveyed internal medicine physicians to explore how institutional actions and policies influenced perceived organizational support (POS) during the COVID-19 pandemic. Higher POS was associated with opportunities to discuss ethnical issues related to COVID-19, adequate access to personal protective equipment, and leadership communication regarding healthcare worker concerns regarding COVID-19. High POS was also associated with lower odds of screening positive for burnout, mental health systems, and intention to leave the profession.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;30:1002-1009.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.
Satterfield K, Rubin JC, Yang D, et al. Learning Health Syst. 2019;4.
The authors interviewed 32 individuals with expertise in learning health systems to explore how such systems can work towards diagnostic excellence. Data, management, and behavioral barriers are discussed, such as the need to standardize measurement, the need for measures that both define and track errors, and that clinicians lack tools to self-assess diagnostic skills. The authors discuss how machine learning and artificial intelligence can be leveraged to advance diagnostic excellence, but that any meaningful integration must be accomplished through mutually beneficial collaborations among researchers and care providers.
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.