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.
Newman-Toker DE, Nassery N, Schaffer AC, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that three diseases (vascular events, infections, and cancers) account for approximately 50% of all serious misdiagnosis-related harm. Based on a sample of 21.5 million US hospital discharges, the authors estimated that 795,000 adults in the US experience serious misdiagnosis-related harm (permanent morbidity or mortality) attributable to these three disease categories each year.
Liberman AL, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2023;10:235-241.
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.
Brimhall KC, Tsai C-Y, Eckardt R, et al. Health Care Manage Rev. 2023;48:120-129.
Workers who experience psychological safety in their organization are more likely to speak up about safety concerns. This study reports on how trust and psychological safety interact to increase error reporting. Results indicate that trust in leaders encouraged error reporting and psychological safety encouraged learning from mistakes.
Kotwal S, Fanai M, Fu W, et al. Diagnosis (Berl). 2021;8:489-496.
Previous studies have used virtual patient cases to help trainees and practicing physicians improve diagnostic accuracy. Using virtual patients, this study found that brief lectures combined with 9 hours of supervised deliberate practice improved the ability of medical interns to correctly diagnose dizziness.
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
Building on prior research on missed myocardial infarction, this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations.
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2022;9:96-106.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:479-488.
Missed or delayed diagnosis of sepsis can lead to serious patient harm. This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis to measure potential misdiagnosis of sepsis in patients discharged from the emergency department (ED) with treat-and-release fluid and electrolyte disorders (FED) or altered mental status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period following the ED visit. The authors suggest SPADE could be used to compare sepsis diagnostic performance across institutions and regions; develop interventions for targeted subgroups; and update early warning systems for sepsis diagnosis.
Diagnostic error is an ongoing patient safety challenge, and can be exacerbated by the hectic pace of the emergency department (ED). This study assessed the feasibility of the Leveraging Patient’s Experience to Improve Diagnosis (LEAPED) program to measure patient-reported diagnostic error after ED discharge. Across three EDs, patient uptake of the program was high. Findings show that 23% of patients did not receive an explanation of their health problem upon discharge, and one-quarter of those patients did not understand the next steps after leaving the ED.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
Sharp AL, Baecker A, Nassery N, et al. Diagnosis (Berl). 2021;8:177-186.
The symptom-disease pair analysis of diagnostic error approach, or SPADE approach, measures diagnostic errors resulting in adverse events using two analytic pathways – the ‘look back’ analysis identifies symptoms associated with adverse events and identifies the symptom-specific harm rate per hospitalization and the ‘look forward’ analysis measures the disease-specific harm rate per symptomatic discharge. Using data from 2009 to 2017, this retrospective analysis looked at Emergency Department (ED) visits within 30 days of a hospitalization for acute myocardial infarction (AMI) to identify symptoms linked to probable missed diagnoses. Within 30 days of a subsequent hospitalization for AMI, common ED discharge diagnoses included chest pain and dyspnea, representing 574 probable missed AMIs. The authors estimate that these results correspond to approximately 10,000 potentially-preventable harms annually in the United States.
Wu AW, Buckle P, Haut ER, et al. J Patient Saf Risk Manag. 2020;25:93-96.
This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.
Newman-Toker DE, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2021;8:67-84.
Prior research based on claims data found that fifteen conditions related to vascular events, infections, and cancers (the ‘Big Three’) account for approximately 50% of all serious misdiagnosis-related harm. Based on a review of 28 studies representing over 91,000 patients, these authors estimated that the median diagnostic error rates for these conditions was 13.6%, ranging from 2.2% (myocardial infarction) to 62.1% (spinal abscess). The median serious misdiagnosis-related harm rate was estimated to be 5.5%, ranging from 1.2% (myocardial infarction) to 35.6% (spinal abscess).
… symptoms and requires time-sensitive treatment, can be a source of diagnostic error and misdiagnosis. Using a large medical malpractice claims database, this study found … that breakdowns in the initial patient-provider encounter (e.g., history and physical examination, symptom assessment, …
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Diagnosis (Berl). 2019;6:227-240.
… (Berl) … Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring … several years. … Newman-Toker DE; Schaffer AC; Yu-Moe CW; Nassery N; Saber Tehrani AS; Clemens GD; Wang Z; Zhu Y; Fanai M; Siegal D. …
Bergl PA, Wijesekera TP, Nassery N, et al. Diagnosis (Berl). 2020;7:3-9.
The Improving Diagnosis in Health Care report launched the universal effort to address diagnostic error and seek strategies for improvement. Analyzing the diagnostic error literature published between 2016 and 2018, this review identifies themes associated with diagnostic error definitions, clinical reasoning teaching methods, and use of artificial intelligence and presents the pros and cons of each topic.
… team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to … to implement the recommended changes, which include a focus on creating opportunities for shifting the process to …