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.
Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.
Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.
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.
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;Epub May 29.
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.
Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;188:e3173-e3181.
Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.
Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;19:340-345.
The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.
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.
Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;45:242-253.
Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.
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.
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.
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
… J Patient Saf … The first surge of the COVID-19 pandemic … of safety issues are described. … Charles MA, Yackel EE, Mills PD, et al. Veterans Health Administration response to the COVID-19 crisis: surveillance to action. J Patient Saf. …
Singh H, Mushtaq U, Marinez A, et al. Jt Comm J Qual Patient Saf. 2022;48:581-590.
… Jt Comm J Qual Patient Saf … Diagnostic error continues to be a … factors contributing to diagnostic safety events. … Singh H, Mushtaq U, Marinez A, et al. Developing the Safer … Care Organizations to address diagnostic errors. Jt Comm J Qual Patient Saf. Epub 2022 Aug 11. …
Bradford A, Shofer M, Singh H. Int J Qual Health Care. 2022;34:mzac068.
… Int J Qual Health Care. … Learning from diagnostic error is a … errors to support improvement . … Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic errors. Int J Qual Health Care . 2022;34(3):mzac068. …
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.
Appelbaum NP, Santen SA, Perera RA, et al. J Patient Saf. 2022;18:370-375.
Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.
Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;18:e1061-e1066.
… J Patient Saf … Delays in diagnosis and treatment can lead to … 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed … challenges, and equipment or supply issues. … Politi RE, Mills PD, Zubkoff L, et al. Delays in diagnosis, treatment, …
Giardina TD, Hunte H, Hill MA, et al. J Patient Saf. 2022;18:770-778.
The 2015 National Academies of Science, Engineering, and Medicine (NASEM) report Improving Diagnosis in Healthcare defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.” This review and interviews with subject matter experts explored how the NASEM definition of diagnostic error has been operationalized in the literature. Of the sixteen included studies, only five operationalized the definition and only three studied communicating with the patient. The authors recommend formulating a set of common approaches to operationalize each of the three components of the NASEM definition. Patients and family should be included in defining the construct of “communication to the patient.”
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.