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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 - 7 of 7 Results
Olson A, Rencic J, Cosby K, et al. Diagnosis (Berl). 2019;6:335-341.
Mitigating diagnostic error has become a critical patient safety concern. As a result, medical education and training programs are increasingly focused on teaching students and residents about diagnostic safety. This article describes the development of a novel interprofessional framework to improve diagnostic competency across health professions education programs. A consensus committee identified 12 key competencies that focus on individual performance (e.g., prioritizing differential diagnosis; utilizing second opinions, decision support, and checklists), teamwork (e.g., engaging patients and families; collaborating with other health professionals), and system-related aspects of clinical care (e.g., developing a culture of diagnostic safety; disclosing and learning from errors). The authors emphasize the innovative aspects of their recommendations and suggest that education programs develop curriculum incorporating these competencies to improve diagnosis. A previous WebM&M commentary discussed an incident involving a diagnostic error.
Graber ML, Rencic J, Rusz D, et al. Diagnosis (Berl). 2018;5:107-118.
Efforts to reduce diagnostic error have mainly focused on safety and quality improvement initiatives. This commentary describes an educational strategy for improving diagnosis. The authors suggest that learners should demonstrate effective use of knowledge, clinical reasoning, system orientation, patient and team engagement, and appropriate attitudes regarding diagnosis to achieve lasting success.
White AA, Brock DM, McCotter PI, et al. J Healthc Risk Manag. 2017;36:34-45.
This study described a demonstration project to enhance error disclosure. The team provided a highly rated training for disclosure coaches who would have around-the-clock availability for hospitals. Further research is needed to determine whether such coaching enhances disclosure practices.
White AA, Brock DM, McCotter PI, et al. J Healthc Risk Manag. 2015;34:30-40.
This AHRQ-funded study surveyed risk managers about programs that provide support for clinicians involved in adverse events, who are often referred to as second victims. Approximately three-quarters of organizations reported having a support program, but they varied widely in structure and staffing. Many of the programs lacked elements recommended by national standards, suggesting significant room for improvement.
Brock DM, Quella A, Lipira L, et al. Acad Med. 2014;89:858-62.
Most existing evidence and guidelines for error disclosure are modeled around physicians, nurses, and risk managers. This commentary recommends that research, policy, and education efforts be designed to understand and construct an effective role for physician assistants in error disclosure.