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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 199 Results
Ali KJ, Goeschel CA, DeLia DM, et al. Diagnosis (Berl). 2023;Epub Oct 5.
To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.
van Moll C, Egberts TCG, Wagner C, et al. J Patient Saf. 2023;19:573-579.
Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.
van Sassen CGM, van den Berg PJ, Mamede S, et al. Adv Health Sci Educ Theory Pract. 2023;28:893-910.
Improving clinical reasoning is an important component of medical education. Using a medical malpractice claims database, researchers in this study reviewed 50 conditions identified 15 priority conditions that can be used to improve clinical reasoning education for general practitioners. The conditions represent common (e.g., eye infection), complex common (e.g., renal insufficiency, cardiovascular disease, cancer), and complex rare conditions (e.g., ectopic pregnancy) and often demonstrate atypical presentations or complex contextual factors important for diagnostic reasoning.
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.
Hooftman J, Dijkstra AC, Suurmeijer I, et al. BMJ Qual Saf. 2023;Epub Aug 9.
Diagnostic errors are common and have many contributing factors. This study analyzed more than 100 serious adverse event (SAE) reports in acute care using four investigation methods (e.g., Diagnostic Error Evaluation Research (DEER) taxonomy, Safer Dx Instrument) to identify common contributing factors. Transitions of care were particularly vulnerable to SAE, often due to incomplete communication between departments. Diagnostic errors occurred most often in the testing, assessment, and follow-up phases, with human factors as the most common contributing factor. Using multiple investigative methods supports more targeted interventions in each phase of diagnosis.

Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.

Diagnostic errors are common in the ambulatory environment. This article discusses five tools to help primary care practices implement diagnostic safety improvement strategies. The authors share overarching considerations to support tool implementation including keeping efforts modest and seeing diagnostic safety beyond the clinical realm.
Kulkarni PA, Singh H. JAMA. 2023;330:317-318.
Artificial intelligence (AI) is an emerging technology to potentially improve care timeliness and diagnostic accuracy. This commentary provides a grounded assessment of this potential by examining clinician knowledge, physician examination skills, and health record data factors that affect the effect of AI chatbots as a tool driving diagnostic safety.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;51:1492-1501.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.
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.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
Rosner BI, Zwaan L, Olson APJ. Diagnosis (Berl). 2023;10:31-37.
Peer feedback is an emerging approach to improving clinicians’ diagnostic reasoning skills. The authors outline several barriers to diagnostic performance feedback and propose solutions to improve diagnostic performance.
Zwaan L, Smith KM, Giardina TD, et al. Patient Educ Couns. 2023;110:107650.
Improving diagnosis and diagnostic error-related harm is a major focus within patient safety. Building on previous research, patients and patient advocates participated in a systematic prioritization exercise and prioritized ten diagnostic error reduction research priorities. Prioritized questions focused on improving care integration/coordination, communication between clinicians and patients/caregivers, improving patient reporting systems, and improved understanding of implicit bias, and underlying factors increasing risk for diagnostic errors among vulnerable patient groups. The authors note that these priorities differed more than those identified previously by diagnostic safety experts and stakeholders.
Sloane JF, Donkin C, Newell BR, et al. J Gen Intern Med. 2023;38:1526-1531.
Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.
Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

Giardina TD, Woodard LCD, Singh H. J Gen Intern Med. 2023;38:1293-1295.
Variations in diagnostic process application reduce the safety of care. This commentary discusses how clinician engagement, community partnerships, and connected care (e.g., telehealth) should interface to improve diagnosis for patients impacted by disparities and implicit bias.
Singh H, Mushtaq U, Marinez A, et al. Jt Comm J Qual Patient Saf. 2022;48:581-590.
Diagnostic error continues to be a significant safety problem. Using a multimethod approach, this study developed a checklist of ten high-priority practices for diagnostic excellence which healthcare organizations can implement to address diagnostic errors. Priority practices include promoting speaking up behaviors through a just culture and psychologically safe environment; patient and family engagement in identifying, understanding, and addressing diagnostic safety concerns; and using multidisciplinary perspectives (including human factors and informatics) to understand factors contributing to diagnostic safety events.
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;37:3965-3972.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.