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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.
This survey-based study of primary care providers revealed a lack of standardization for the tracking, receiving, and reporting of laboratory results. Even practices with integrated electronic medical records reported the need for a back-up tracking system to ensure important test results are not lost.
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
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
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.
Delayed diagnosis from false-negative Papanicolaou (Pap) tests can have tragic results. This study re-screened liquid-based Pap tests of women who were later diagnosed with endometrial carcinoma. Of the 27 rescreened samples, 16 were recategorized to positive. Through root cause analysis, latent and active failures were identified, and several quality improvement initiatives were implemented.
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.
Raab SS, Grzybicki DM, Zarbo RJ, et al. Am J Clin Pathol. 2007;128:817-24.
This AHRQ-funded study of cervical cancer screening results found a remarkably low incidence of missed malignancies. The authors analyzed Papanicolaou test results and the results of subsequent biopsies and found that the results were discordant in only 0.3% of cases, with most of these inconsistencies being clinically insignificant. Delayed diagnosis of cancer is a common cause of malpractice suits in ambulatory care. Although a prior study by Raab and colleagues found a higher overall error rate in anatomic pathology cancer diagnosis, this study documents that the US cervical cancer screening system appears to be very effective at preventing squamous cervical cancer. However, a systematic review of missed or delayed cancer diagnoses found that misdiagnosis of four common types of cancer—melanoma, as well as cancer of the breast, lung, or colon—remains common.
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.