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.
Clayton DA, Eguchi MM, Kerr KF, et al. Med Decis Making. 2023;43:164-174.
… errors. Using data from the Melanoma Pathology Study (M-PATH) and Breast Pathology Study (B-PATH), researchers … metacognition sensitivity were more likely to request a second opinion for incorrect diagnosis than they were for a correct diagnosis. … Clayton DA, Eguchi MM, Kerr KF, et al. Are pathologists …
Bell SK, Delbanco T, Elmore JG, et al. JAMA Netw Open. 2020;3:e205867.
This study surveyed over 22,800 patients across three health care organizations to assess how often patients who read open ambulatory visit notes perceive mistakes in the notes. The analysis found that 4,830 patients (21%) perceived a mistake in one or more notes in the past 12 months and that 42% of those patients considered the mistake to be somewhat or very serious. The most common very serious mistakes involved incorrect diagnoses; medical history; allergy or medication; or tests, procedures, or results. Older and sicker patients were more likely to report a serious error compared to younger and healthier patients. Using open notes and encouraging patient engagement can improve record accuracy and prevent medical errors
This study held focus groups with breast cancer providers to better understand attitudes and experiences regarding communicating with patients about diagnostic errors. Researchers presented three hypothetical vignettes for discussion. Participants identified challenges related specifically to breast cancer as well as challenges stemming from team-based care. To improve communication about these errors, participants recommended educating patients, being honest and empathetic, and focus on the positive and the patient’s future.
Disclosure of medical errors is a recommended patient safety practice. This focus group study of pathologists found that most pathologists believe treating clinicians should disclose pathology errors and express concern that treating clinicians do not understand the inherent limitations of pathologic diagnosis. The authors suggest that developing consensus guidelines may improve disclosure of pathology errors.
Elmore JG, Tosteson AN, Pepe MS, et al. BMJ. 2016;353:i3069.
This study found that eliciting second opinions in pathology improved the accuracy of breast histopathology specimens. This work provides further evidence that diagnostic accuracy can be enhanced with second opinions. The authors suggest that implementing multiple clinician review may augment the diagnostic process.
Bell SK, Mejilla R, Anselmo M, et al. BMJ Qual Saf. 2017;26:262-270.
… Approximately one-fourth of patients identified a possible documentation error in their records, illustrating the potential of this approach as a way to engage patients in safety efforts. … Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: a …
Elmore JG, Longton GM, Carney PA, et al. JAMA. 2015;313:1122-1132.
… of cancer and other diseases, but prior research has shown a small yet consistent rate of errors in cancer diagnosis … quantify error rates in breast cancer diagnosis by having a broad sample of pathologists review a standardized set of biopsies whose diagnoses had been …
Gallagher TH, Cook AJ, Brenner RJ, et al. Radiology. 2009;253.
… discuss mammogram results directly with patients, but only a minority would disclose any information about an error in … error and how it occurred. Errors in cancer diagnosis are a frequent cause of malpractice lawsuits, but in this study, … Dr. Thomas Gallagher, was interviewed for AHRQ WebM&M in January 2009. …
Phillips DP, Barker GEC, Eguchi MM. Arch Intern Med. 2008;168:1561-6.
… patients. This examination of death certificates found a striking increase in fatal medication errors among … alcohol or street drugs. Similar findings were noted in a prior study that analyzed deaths between 1983 and … safe prescribing in the outpatient arena are discussed in a recent commentary . …
Stille CJ, Jerant A, Bell D, et al. Ann Intern Med. 2005;142:700-708.
This review examines the literature on coordination of care and its effectiveness to better understand how a generalist operates in an increasingly complex health care delivery system. The authors present six key recommendations. These include the need for greater evidence to substantiate the value of care coordination in improving health outcomes; a belief that a generalist’s practice represents an effective hub for coordinating care in most patients; and that improved communication and coordination among generalists, specialists, patients, and their family members must be fostered. The authors advocate for greater emphasis on teamwork, increased education about effective communication and collaboration skills, and wider adoption and application of medical informatics.