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.
van Sassen C, Mamede S, Bos M, et al. BMC Med Educ. 2023;23:474.
Clinical reasoning is an important component of medical education. In this study, first-year general practice residents concluded that diagnostic error cases, both with and without malpractice claim information, are equally effective for clinical reasoning education.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Schmidt HG, Mamede S. Diagnosis (Berl). 2023;10:38-42.
Critical thinking skills can enhance diagnostic reasoning. This article discusses how deliberate reflection can improve diagnosis and how deliberate reflection can be integrated into digital decision support tools.
Staal J, Hooftman J, Gunput STG, et al. BMJ Qual Saf. 2022;31:899-910.
Enhancing clinical reasoning skills is an emerging strategy to reduce diagnostic errors. This meta-analysis of 26 studies estimated that cognitive reasoning tools can lead to small improvements in diagnostic accuracy.
Kuhn J, van den Berg P, Mamede S, et al. Adv Health Sci Edu. 2022;27:189-200.
Diagnostic calibration is the relationship between individual confidence in diagnostic decision making and diagnostic accuracy, and it can lead to diagnostic error or overtesting. This study investigated whether feedback would improve general-practice residents’ diagnostic calibration on difficult cases. Results did not show that feedback on diagnostic performance improved diagnostic calibration.
van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47:234-241.
Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.
ALQahtani DA, Rotgans JI, Mamede S, et al. Med Educ. 2018;52:1288-1298.
In this educational study, internal medicine resident physicians were randomized to solve standardized cases with and without time pressure. The time-pressured group performed worse, and they reported more stress and generated fewer possible diagnoses.
Norman GR, Monteiro SD, Sherbino J, et al. Acad Med. 2017;92:23-30.
Decision making is typically either intuitive or analytical. This commentary discusses the two types of decision making, how heuristics and cognitive biases affect diagnostic reasoning, and strategies to reduce diagnostic error.
Schmidt HG, Van Gog T, Schuit SC, et al. BMJ Qual Saf. 2017;26:19-23.
As diagnostic errors continue to rise to the forefront of patient safety, identifying specific drivers and target areas will be critical to improving diagnosis. To examine how patients' disruptive behaviors may provoke emotional responses in physicians that contribute to diagnostic inaccuracy, researchers in the Netherlands had 63 family practice residents evaluate 6 clinical vignettes that presented patients as either difficult or neutral. For patients that displayed distressing behaviors, physicians' mean diagnostic accuracy was significantly lower, even though they spent the same amount of time contemplating the diagnosis. In the related study, 74 internal medicine residents were randomized to 8 clinical vignettes that were identical except for whether the patient displayed difficult or neutral behaviors. Once again, mean diagnostic scores were significantly lower for difficult compared to neutral patients' vignettes, and time spent reaching a diagnosis was similar across groups. Physicians recalled fewer clinical findings and more behaviors from difficult-patient vignettes. This finding suggests that the devotion of mental resources to dealing with behaviors may hinder clinical processing. A recent PSNet perspective reviewed emerging progress on addressing diagnostic errors.
ALQahtani DA, Rotgans JI, Mamede S, et al. Acad Med. 2016;91:710-716.
Diagnosis is a critical area of patient safety. Prior research demonstrates that physicians perceive time pressure as an impediment to diagnosis, but this has not been objectively documented. This educational simulation study examined the ability of internal medicine residents to correctly diagnose written cases with and without time pressure. Residents under time pressure had reduced diagnostic accuracy, and this decrement was more marked for difficult cases. These results demonstrate the benefit of allowing physicians more time for accurate diagnosis, consistent with recent Institute of Medicine recommendations to examine novel models of care and reimbursement to foster diagnostic safety. A recent PSNet interview discussed diagnostic errors and how to reduce them.
Schmidt HG, Mamede S, Van den Berge K, et al. Acad Med. 2014;89:285-91.
Cognitive biases can lead to diagnostic errors, and reflective reasoning has been promoted to enhance diagnostic accuracy. This study of internal medicine trainees examined whether prior exposure to media-distributed disease information would influence subsequent diagnostic accuracy and found that similarities between prior reading and case descriptions contributed to diagnostic inaccuracy, highlighting the importance of availability bias. The participants were then asked to return to the cases, reflect on their previous diagnosis, and consider alternate diagnoses. This extended reflection process led to improvements in diagnostic accuracy, consistent with earlier reflective reasoning studies. An accompanying editorial recommends encouraging reflection and explaining its benefits when teaching diagnostic thinking.
Mamede S, Van Gog T, Van den Berge K, et al. Acad Med. 2014;89:114-20.
Internal medicine residents made more diagnostic errors during complex clinical cases when a salient distracting feature—a case finding strongly associated with a particular disease that is actually unrelated to the problem—appeared near the beginning of the case description, but not when presented toward the end.
Croskerry P, Singhal G, Mamede S. BMJ Qual Saf. 2013;22 Suppl 2:ii58-ii64.
Experienced diagnosticians rely on heuristics—rules of thumb—to recognize clinical patterns and establish diagnoses efficiently. However, this process can lead to diagnostic error, as numerous cognitive biases can adversely affect the diagnostic reasoning process. This two-part series reviews the psychological origins of cognitive biases, examines the theoretical basis behind "debiasing" approaches (strategies for averting specific cognitive biases), and proposes a framework for preventing diagnostic errors through educational and systems-based approaches. Two of the most common cognitive biases, premature closure (diagnosing a patient on the basis of preliminary or incomplete information) and anchoring (failing to reconsider a provisional diagnosis in the face of conflicting information) are vividly illustrated in an AHRQ WebM&M commentary. Dr. Pat Croskerry, the lead author of these articles, was interviewed by AHRQ WebM&M in 2010.
Mamede S, Splinter TAW, Van Gog T, et al. BMJ Qual Saf. 2012;21:295-300.
This study described the role of reflection in preventing physicians from being overly influenced by salient clinical features that may misdirect diagnostic reasoning. The authors advocate for deliberate reflection as a tool to prevent diagnostic errors.
Mamede S, Van Gog T, Van den Berge K, et al. JAMA. 2010;304:1198-1203.
Diagnostic errors are frequently ascribed to cognitive errors on the part of clinicians. Prominent among these is availability bias, when clinicians choose the most available diagnosis—the first that comes to mind—when faced with a complex diagnostic scenario. In this Dutch study, internal medicine residents were presented with a series of diagnosed cases, then given cases with similar symptoms and asked to record their provisional diagnoses. The investigators did find evidence of availability bias, but also found that asking residents to reflect on their diagnostic process mitigated the effects of availability bias. Diagnostic errors have been termed the next frontier in patient safety, and an AHRQ WebM&M commentary discusses reflective practice and other methods of avoiding cognitive error in diagnosis.