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.
Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.
Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.
Previous research has identified gender and racial disparities in the burden of diagnostic errors. In this study, researchers conducted a series of human-centered design workshops with a diverse set of stakeholders who generated a set of design challenges, principles, and solutions for addressing diagnostic disparities, improving healthcare quality, and promoting equity and inclusion of marginalized patients. Participants also identified two prototypes for the solutions – a visit preparation guide to teach patients how to advocate for themselves and a tool for identifying patients who may be at increased risk for experiencing a diagnostic error.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
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.
Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2022;57:654-667.
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;30:1002-1009.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.
Gleason KT, Harkless G, Stanley J, et al. Nurs Outlook. 2021;69:362-369.
To reduce diagnostic errors, the National Academy of Medicine (NAM) recommends increasing nursing engagement in the diagnostic process. This article reviews the current state of diagnostic education in nursing training and suggests inter-professional individual and team-based competencies to improve diagnostic safety.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Wright B, Lennox A, Graber ML, et al. BMC Health Serv Res. 2020;20:897.
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm. The authors synthesized systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures. The review identified several avenues for improving closed-loop communication through the use of technology, audit and feedback, and use of point-of-care or bedside testing.
Gleason KT, Jones RM, Rhodes C, et al. J Patient Saf. 2021;17:e959-e963.
This study analyzed malpractice claims to characterize nursing involvement in diagnosis-related (n=139) and failure-to-monitor malpractice (n=647) claims. The most common contributing factors included inadequate communication among providers (55%), failure to respond (41%), and documentation failures (28%). Both diagnosis-related and physiologic monitoring cases listing communication failures among providers as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, respectively). Healthcare organizations need to take actions to enhance nurses’ knowledge and skills to be better engage them in the diagnostic process, such as competency training and assessment.
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.
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Gupta A, Graber ML. Ann Intern Med. 2019;170:HO2-HO3.
Standardized approaches can enhance team communication, process reliability, and diagnostic thinking. This commentary suggests that checklist use is an underutilized low-cost intervention to reduce diagnostic error. The authors describe process checklists, which can can help manage cognitive challenges, and content checklists, which provide differential diagnoses for common symptoms.
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.
This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.
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.
Whitehead NS, Williams L, Meleth S, et al. J Hosp Med. 2018.
Test results pending at the time of hospital discharge can lead to a delay in diagnosis and represent a significant patient safety risk. This systematic review found that certain electronic and educational interventions may improve documentation and awareness of pending test results. The authors suggest that further research is needed to understand how these interventions affect processes and outcomes.