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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 425 Results

PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights a funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement.
Richmond JG, Burgess N. J Health Organ Manag. 2023;Epub Feb 28.
Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.
Pisciotta W, Arina P, Hofmaenner D, et al. Anaesthesia. 2023;78:501-509.
A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.

Tamayo-Sarver J. Fast Company. March 13, 2023.

Artificial intelligence (AI) harbors risks and biases that can misinform clinicians, researchers, and patients. This article discusses experience with an AI application in the emergency setting and the diagnostic mistakes it made. The author offers caution when proceeding with the use of AI as a diagnostic tool.
WebM&M Case March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

Satariano A, Metz C. New York Times. March 5, 2023.

Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and timeliness improvement. This article discusses a successful AI breast cancer screening program in Hungary and its potential to illuminate efforts to spread AI-enhanced diagnosis as a tool for physician decision making.
Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.
Morgan DJ, Malani PN, Diekema DJ. JAMA. 2023;Epub Mar 2.
The effective use of resources through stewardship initiatives can support error reduction through focusing actions of care. This commentary discusses how diagnostic stewardship can enhance diagnostic testing behaviors across the diagnostic process.
Liberman AL, Holl JL, Romo E, et al. Acad Emerg Med. 2022;30:187-195.
A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. This article describes how interdisciplinary teams used a failure modes, effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures, and highlight existing safeguards. The FMECA process identified several steps in the diagnostic process as the most critical failures to address, including failure to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to obtain an accurate history, and failure to consider a stroke diagnosis during triage.
Freund O, Azolai L, Sror N, et al. J Hosp Med. 2023;Epub Feb 13.
The COVID-19 pandemic led to unprecedented numbers of patients seen in the emergency department (ED), some who had COVID-19, some who had a different diagnosis, and some who had both. This study analyzes patients who presented to the ED with COVID-19 and signs of another diagnosis that was missed. Approximately one-third of patients with a second concurrent diagnosis experienced a diagnostic delay. Factors that may have influenced the missed diagnosis include ED overcrowding and anchoring heuristics.
Giardina TD, Woodard LCD, Singh H. J Gen Intern Med. 2023;Epub Jan 5.
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.
Crapanzano KA, Deweese S, Pham D, et al. J Behav Health Serv Res. 2023;50:236-262.
Patients with mental illness may receive lower quality healthcare care than patients without mental illness. In this review of implicit and explicit biases of healthcare providers, the majority demonstrated unfavorable clinical decisions towards patients with mental illness. A prior WebM&M describes how diagnostic overshadowing of a patient with substance use disorder led to undertreatment of a cardiovascular condition.
Sempere L, Bernabeu P, Cameo J, et al. Inflamm Bowel Dis. 2023;Epub Jan 31.
Women often experience misdiagnosis and diagnostic delays due to process failures and implicit bias. This multicenter cohort study including 190 patients found that women were more likely to experience delays in diagnosis and misdiagnosis of inflammatory bowel disease, as compared to men. Researchers found that these inequities in misdiagnosis occurred across all healthcare settings (emergency department, primary care, gastroenterology, and hospital admission).
Bell SK, Dong ZJ, DesRoches CM, et al. J Am Med Inform Assoc. 2023;Epub Jan 24.
Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.
Schnock KO, Garber A, Fraser H, et al. Jt Comm J Qual Patient Saf. 2023;49:89-97.
Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.
Harada Y, Otaka Y, Katsukura S, et al. BMJ Qual Saf. 2023;Epub Jan 23.
Context, such as patient, clinician, location, or specialty, can affect the type and frequency of diagnostic errors. In this novel study, the diagnostic errors of a cohort of clinicians who practice in multiple locations (i.e., outpatient and emergency department) with different referral types (i.e., scheduled visit, urgent visit, emergency visit) was evaluated. Using the Revised Safer Dx instrument, researchers identified significantly more diagnostic errors in patients with scheduled visits compared to urgent or emergent referrals. The results indicate, that among clinicians in the same specialty, it may be contextual factors (i.e., referral type) that affect diagnostic errors rather than specialty.
Edlow JA, Pronovost PJ. JAMA. 2023;329:631-632.
Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.
Reyes AM, Royan R, Feinglass J, et al. JAMA Surg. 2023;Epub Jan 18.
Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.
Curated Libraries
January 19, 2023
The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...