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.
Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.
Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.
Artificial intelligence (AI) is an emerging technology to potentially improve care timeliness and diagnostic accuracy. This commentary provides a grounded assessment of this potential by examining clinician knowledge, physician examination skills, and health record data factors that affect the effect of AI chatbots as a tool driving diagnostic safety.
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;Epub May 29.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
Sloane JF, Donkin C, Newell BR, et al. J Gen Intern Med. 2023;38:1526-1531.
Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.
Giardina TD, Woodard LCD, Singh H. J Gen Intern Med. 2023;38:1293-1295.
… J Gen Intern Med … Variations in diagnostic process … disparities and implicit bias . … Giardina TD, Woodard LD, Singh H. Advancing diagnostic equity through clinician … engagement, community partnerships, and connected care. J Gen Intern Med. Epub 2023 Jan 5. 10.1007/s11606-022-07966-8 …
Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.
Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.
Singh H, Mushtaq U, Marinez A, et al. Jt Comm J Qual Patient Saf. 2022;48:581-590.
… Jt Comm J Qual Patient Saf … Diagnostic error continues to be a … factors contributing to diagnostic safety events. … Singh H, Mushtaq U, Marinez A, et al. Developing the Safer … Care Organizations to address diagnostic errors. Jt Comm J Qual Patient Saf. Epub 2022 Aug 11. …
Bradford A, Shofer M, Singh H. Int J Qual Health Care. 2022;34:mzac068.
Learning from diagnostic error is a complex undertaking. This commentary introduces Measure Dx, a tool providing guidance for health care organizations to identify and evaluate diagnostic errors to support improvement.
Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf. 2022;18:e877-e882.
Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental – rather than performance – goals).
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;37:3965-3972.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.
Giardina TD, Hunte H, Hill MA, et al. J Patient Saf. 2022;18:770-778.
The 2015 National Academies of Science, Engineering, and Medicine (NASEM) report Improving Diagnosis in Healthcare defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.” This review and interviews with subject matter experts explored how the NASEM definition of diagnostic error has been operationalized in the literature. Of the sixteen included studies, only five operationalized the definition and only three studied communicating with the patient. The authors recommend formulating a set of common approaches to operationalize each of the three components of the NASEM definition. Patients and family should be included in defining the construct of “communication to the patient.”
Bradford A, Shahid U, Schiff GD, et al. J Patient Saf. 2022;18:521-525.
Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.