Sorry, you need to enable JavaScript to visit this website.
Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Back to all filters
Approach to Improving Safety
Clinical Area
Safety Target
Displaying 1 - 20 of 271 Results
Mangus CW, James TG, Parker SJ, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 12.
The emergency department (ED) presents unique challenges in making and communicating an accurate diagnosis. This study sought perspectives of patients, nurses, and physicians about diagnostic vulnerabilities faced in the ED and suggested interventions. All three groups proposed that inter- and intrateam communication could be improved, for example with structured hand-offs between emergency medical services and the ED, and between members of the care team.
Bradford A, Meyer AND, Khan S, et al. BMJ Qual Saf. 2024;Epub Apr 4.
Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood, and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis and estimating error rates.
Sokol-Hessner L, Dechen T, Folcarelli P, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 7.
Medical errors can cause physical, financial, or emotional harm to patients. This survey identified prolonged emotional impacts (greater than one year) among the majority of US adults who experienced a medical error. Survey respondents who were female or with a lower socioeconomic status were more likely to report prolonged emotional impacts; organizational factors such as lack of organizational disclosure guidelines and no patient or family reporting process also increased risk of prolonged emotional impacts.
Murphy DR, Kadiyala H, Wei L, et al. J Telemed Telecare. 2024;Epub Apr 1.
The expansion of telehealth has improved access to care, but concerns have been raised about potential for diagnostic errors. In this study, researchers used the Safer Dx Trigger tool framework to develop an electronic trigger to identify delayed diagnoses during primary care telehealth visits at a Veterans Health Affairs (VHA) facility. Applying the trigger tool to a random sample of 100 telehealth visits with a subsequent unplanned visit (emergency department, hospital or primary care) yielded a positive predictive value of 11%.
Kwan JL, Calder LA, Bowman CL, et al. Can J Surg. 2024;67:e58-e65.
Research into diagnostic errors frequently focuses on hospitals, emergency departments, and primary care, with less focus on surgical diagnostic errors. This study used medico-legal cases and complaints to characterize surgical diagnostic errors. Most errors occurred post-operatively (e.g., failure to recognize clinical deterioration) and were attributed to providers’ clinical decision-making.
Liu SK, Bourgeois FC, Dong J, et al. Diagnosis (Berl). 2024;11:63-72.
Patient feedback on diagnostic errors may improve the quality and safety of care. As part of the larger OurDx study, this analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
Sittig DF, Yackel EE, Singh H. J Gen Intern Med. 2023;38:940-942.
Large-scale technology modifications can contribute to organizational disfunction. This commentary discusses five approaches to managing disruption associated with electronic health record modernization that establish cultural, functionality, staff, design, and monitoring conditions to reduce stress and the potential for patient harm during technology improvements.
Ali KJ, Goeschel CA, DeLia DM, et al. Diagnosis (Berl). 2024;11:17-24.
To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.
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.

Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.

Diagnostic errors are common in the ambulatory environment. This article discusses five tools to help primary care practices implement diagnostic safety improvement strategies. The authors share overarching considerations to support tool implementation including keeping efforts modest and seeing diagnostic safety beyond the clinical realm.
Kulkarni PA, Singh H. JAMA. 2023;330:317-318.
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.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;51:1492-1501.
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.
Zwaan L, Smith KM, Giardina TD, et al. Patient Educ Couns. 2023;110:107650.
Improving diagnosis and diagnostic error-related harm is a major focus within patient safety. Building on previous research, patients and patient advocates participated in a systematic prioritization exercise and prioritized ten diagnostic error reduction research priorities. Prioritized questions focused on improving care integration/coordination, communication between clinicians and patients/caregivers, improving patient reporting systems, and improved understanding of implicit bias, and underlying factors increasing risk for diagnostic errors among vulnerable patient groups. The authors note that these priorities differed more than those identified previously by diagnostic safety experts and stakeholders.
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.
Variations in diagnostic process application reduce the safety of care. This commentary discusses how clinician engagement, community partnerships, and connected care (e.g., telehealth) should interface to improve diagnosis for patients impacted by disparities and implicit bias.
Bell SK, Dong ZJ, DesRoches CM, et al. J Am Med Inform Assoc. 2023;30:692-702.
Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.
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.
Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.
Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.