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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 24 Results
Nakhleh RE, Nosé V, Colasacco C, et al. Arch Pathol Lab Med. 2016;140:29-40.
Misinterpretation of test results can have harmful consequences for patients. This guideline synthesized the literature on surgical pathology and cytology case reviews to determine recommendations to improve diagnostic accuracy, such as involving anatomic pathologists in developing procedures to detect disagreements and errors, conducting case reviews in a timely fashion, and continuously tracking and documenting case review findings.
West DR, James KA, Fernald DH, et al. J Am Board Fam Med. 2014;27:796-803.
J Am Board Fam Med … J Am Board Fam Med … This survey-based study of primary care … lost. … West DR, James KA, Fernald DH, Zelie C, Smith ML, Raab SS. Laboratory medicine handoff gaps experienced by … collaborative ambulatory practices and partners (SNOCAP).  J Am Board Fam Med . 2014;27(6):796-803. …
Raab SS. MLO Med Lab Obs. 2014;46:8-10.
This commentary illustrates the process of decision-making in pathology to reveal factors contributing to disagreements in interpretation of test results. Emphasizing how differences between slow thinking and fast thinking can cause interpretation errors, the author recommends system-level approaches and team-based solutions, respectively, to improve safety in pathology.
WebM&M Case March 1, 2013
… and reports the results, which the ordering clinician(s) receives. Each of these steps carries the possibility of … processes currently used for classifying error severity. Raab and colleagues ( ref 9 ) recommended an error severity … University of Newfoundland St. John's, NL, Canada … Stephen S. Raab, MD … Professor, Anatomic Pathology Memorial …
Smith ML, Wilkerson T, Grzybicki DM, et al. Am J Clin Pathol. 2012;138:367-373.
Entering pathology test results into the wrong patient’s record but discovering the error before the results are released is a type of pathology near miss. Using Lean quality improvement program (LQIP), including culture change, one anatomic pathology laboratory sought to reduce both process- and operator-dependent near-miss events. The laboratory was able to decrease the frequency of process-dependent near-miss events, though not the operator-dependent events. The authors cite lack of leadership buy-in as a major challenge.  
Smith ML, Raab SS. Adv Anat Pathol. 2012;19:331-337.
Diagnostic error in pathology can result in delayed treatment or initiation of incorrect treatment. Peer review, or second opinion, is used by many laboratories to improve diagnostic accuracy and precision. This paper describes the use of Lean A3 method to identify and reduce root causes of cognitive and latent errors in pathology misdiagnosis.
Sams SB, Currens HS, Raab SS. Am J Clin Pathol. 2012;137:248-254.
… Am J Clin Pathol … Delayed diagnosis from false-negative … initiatives were implemented. … Sams SB,  Currens HS, Raab SS. Liquid-based Papanicolaou tests in endometrial … error root cause analysis, and quality improvement. Am J Clin Pathol. 2012;137(2):248-254. 10.1309/ajcplfbk1a2xjdqi …
Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.
… CA: a cancer journal for clinicians … CA Cancer J Clin … This review discusses quality of pathology testing … calls for improvements to prevent diagnostic errors . … Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.   …
Raab SS, Andrew-JaJa C, Grzybicki DM, et al. J Low Genit Tract Dis. 2009;12:103-110.
Lean methodology is a quality improvement method to increase safety and efficiency in healthcare. In this small study, five clinicians in a gynecology practice used Lean methods to redesign the workflow to improve the diagnostic accuracy of Pap tests. Although two clinicians dropped out of the study, the remaining three improved Pap test quality and diagnostic accuracy, maintained up to six months.
Suba EJ, Pfeifer JD, Raab SS. J Urol. 2007;178:1245-8.
This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.
Pathologists C of A, Valenstein PN, Raab SS, et al. Arch Pathol Lab Med. 2006;130:1106-1113.
The investigators analyzed information on misidentified laboratory specimens and found that such errors are common. Most errors are detected prior to results being communicated and are rarely associated with adverse patient incidents.
Raab SS, Grzybicki DM, Janosky JE, et al. Cancer. 2005;104:2205-13.
This AHRQ-funded study estimated a 12% error rate in cancer diagnosis based on discrepant evaluation of two specimens from the same organ. Investigators compiled web-based pathologic data from four institutions and created a standardized system to establish correlation error frequencies between cytologic and histologic samples during a 6-month period (eg, bronchial washings and a lung biopsy). Findings suggested that error rates were dependent on the institution and an association existed between the institution and error cause, but agreement was lacking on whether these errors resulted from misinterpretation or poor clinical sampling. Disagreement also existed on the clinical significance of the errors, an issue that results from an undeveloped taxonomy in this arena. While a previous systematic review used autopsy findings to report on clinically significant errors, this study builds on that literature by employing a method that is not limited by the overall low rate of autopsies performed nationally.