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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 - 20 of 20 Results
Newman-Toker DE, Nassery N, Schaffer AC, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that three diseases (vascular events, infections, and cancers) account for approximately 50% of all serious misdiagnosis-related harm. Based on a sample of 21.5 million US hospital discharges, the authors estimated that 795,000 adults in the US experience serious misdiagnosis-related harm (permanent morbidity or mortality) attributable to these three disease categories each year.
Liberman AL, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2023;10:235-241.
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.
Krevat S, Samuel S, Boxley C, et al. JAMA Netw Open. 2023;6:e238399.
The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
… diagnoses linked to downstream sepsis hospitalizations. … Nassery N, Horberg MA, Rubenstein KB, et al. Antecedent …
Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18:1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.
Schaffer AC, Babayan A, Einbinder JS, et al. Obstet Gynecol. 2021;138:246-252.
Adverse events in obstetrics threaten the safety of both maternal and infant patients. This study identified a significant reduction in malpractice claims among obstetrician-gynecologists after participation in simulation training focused on team training and crisis management.
Sharp AL, Baecker A, Nassery N, et al. Diagnosis (Berl). 2021;8:177-186.
The symptom-disease pair analysis of diagnostic error approach, or SPADE approach, measures diagnostic errors resulting in adverse events using two analytic pathways – the ‘look back’ analysis identifies symptoms associated with adverse events and identifies the symptom-specific harm rate per hospitalization and the ‘look forward’ analysis measures the disease-specific harm rate per symptomatic discharge. Using data from 2009 to 2017, this retrospective analysis looked at Emergency Department (ED) visits within 30 days of a hospitalization for acute myocardial infarction (AMI) to identify symptoms linked to probable missed diagnoses. Within 30 days of a subsequent hospitalization for AMI, common ED discharge diagnoses included chest pain and dyspnea, representing 574 probable missed AMIs. The authors estimate that these results correspond to approximately 10,000 potentially-preventable harms annually in the United States.  
Newman-Toker DE, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2021;8:67-84.
Prior research based on claims data found that fifteen conditions related to vascular events, infections, and cancers (the ‘Big Three’) account for approximately 50% of all serious misdiagnosis-related harm. Based on a review of 28 studies representing over 91,000 patients, these authors estimated that the median diagnostic error rates for these conditions was 13.6%, ranging from 2.2% (myocardial infarction) to 62.1% (spinal abscess). The median serious misdiagnosis-related harm rate was estimated to be 5.5%, ranging from 1.2% (myocardial infarction) to 35.6% (spinal abscess).
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Diagnosis (Berl). 2019;6:227-240.
Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring these errors has made it challenging to quantify their impact. This study utilized a large national database of closed malpractice claims to estimate the frequency and severity of diagnostic errors. Researchers also sought to determine the types of diagnoses most vulnerable to misdiagnosis. Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases resulted in permanent disability or death. These findings corroborate earlier research on closed malpractice claims in primary care and emergency department settings. Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity events: vascular events (such as myocardial infarction and stroke), infections (such as sepsis), and cancer. This study represents an important step forward in identifying areas for improvement in diagnosis, but caution should be exercised in extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced by patients. A previous PSNet perspective discussed momentum in the field of diagnostic error over the past several years.
Bergl PA, Wijesekera TP, Nassery N, et al. Diagnosis (Berl). 2020;7:3-9.
The Improving Diagnosis in Health Care report launched the universal effort to address diagnostic error and seek strategies for improvement. Analyzing the diagnostic error literature published between 2016 and 2018, this review identifies themes associated with diagnostic error definitions, clinical reasoning teaching methods, and use of artificial intelligence and presents the pros and cons of each topic.
Mane KK, Rubenstein KB, Nassery N, et al. BMJ Qual Saf. 2018;27:567-570.
System approaches are required to achieve sustainable improvements in health care. This commentary describes a big data analysis framework and applied it to the development of a dashboard that tracks diagnostic safety across an organization. The prototype is designed to help organizations visualize weaknesses in diagnostic performance, target specific problems, and enable learning and operational improvements to prevent future misdiagnoses.
Tarnutzer AA, Lee S-H, Robinson K, et al. Neurology. 2017;88:1468-1477.
Delayed diagnosis of stroke can lead to preventable disability. This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found that overall 9% of strokes were misdiagnosed. The risk of misdiagnosis was higher if stroke symptoms were transient, nonspecific, or mild. The authors suggest that interventions to improve stroke diagnosis should focus on these specific disease presentations.
Graber ML, Siegal D, Riah H, et al. J Patient Saf. 2019;15:77-85.
Although heath information technology (IT) has improved patient safety, studies have shown that implementing electronic health records can introduce new errors. This study examined closed malpractice claims related to health IT. Most cases occurred in ambulatory care settings, suggesting that current health IT may not be optimally designed to support safety in those settings. Cases involving medication errors, diagnostic errors, or treatment complications were almost equally prevalent, indicating that health IT vulnerabilities span multiple tasks and functions. Software design issues and implementation problems also played a role in these incidents. These findings emphasize the need to reexamine health information technologies and how they are implemented in health care systems to enhance safety. A recent PSNet perspective examined challenges in health IT implementation, and another perspective discussed the need for innovations in health IT usability.
Siegal D, Ruoff G. J Healthc Risk Manag. 2015;34:18-25.
Analysis of malpractice claims can identify trends and determine opportunities for improvement. This commentary discusses an incident involving delayed diagnosis of Ebola in the United States and other diagnostic failures to illustrate how local and comparative data can be utilized to inform the design of risk reduction strategies.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22:672-680.
The patient safety consequences of diagnostic errors have been receiving greater attention in the past few years, after being relatively neglected in the early period of the safety movement. The results of this study will likely add momentum to this "next frontier" in patient safety. The authors analyzed 25 years of closed malpractice claims from the National Practitioner Data Bank and found that diagnostic errors—primarily in the outpatient setting—were both the most common and the most costly (in terms of total payments) type of claim. Compared with other types of errors, diagnostic errors were more likely to result in serious patient harm or death. Although data from closed malpractice claims may not be representative of all error types, it is clear from this study that diagnostic errors account for a large proportion of preventable patient harm. Recent reviews have identified strategies to improve diagnostic accuracy at the individual clinician level and at the system level. The human costs of a fatal diagnostic error—for the patient and the clinician—were vividly illustrated in a recent graphic-novel style article.