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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 47 Results
Perspective on Safety November 27, 2023
… Adv Nurs . 2016;72(12):2966-2979. doi:10.1111/jan.13033 … Joan … Bryan … Sarah … Stanley … Gale … Mossburg … Joan Stanley … Bryan Gale … Sarah … when they enter the workforce. Maybe it’s because they don’t understand the environment in which they’re asked to …

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Joan Stanley

Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN).  We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Huff NR, Liu G, Chimowitz H, et al. Int J Nurs Stud Adv. 2022;5:100111.
Negative emotions can adversely impact perception of both patient safety and personal risks. In this study, emergency nurses were surveyed about their emotions (e.g., afraid, calm), emotional suppression and reappraisal behaviors, and perceived risk of personal and patient safety during the COVID-19 pandemic. Nurses reported feeling both positive and negative emotions, but only negative emotions were significantly associated with greater perception of risk.
Shimizu T, Graber ML. Diagnosis (Berl). 2022;9:311-315.
Improving diagnostic reasoning skills can reduce diagnostic errors. These authors discuss how insight – or the spontaneous emergence of the correct answer at a later point in time – can be incorporated into the diagnostic process and approaches to nurturing insight through existing strategies (e.g., cognitive forcing functions, mnemonics) and enhancing both critical and creative thinking.  
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.
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.
Graber ML, Berg D, Jerde W, et al. Diagnosis (Berl). 2018;5:257-266.
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.
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.
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.
Gleason KT, Davidson PM, Tanner EK, et al. Diagnosis (Berl). 2017;4:201-210.
In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.