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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 103 Results
Lippi G, Simundic A-M, Plebani M. Clin Chem Lab Med. 2020;58:1070-1076.
This paper discusses potential vulnerabilities in the laboratory diagnosis of COVID-19, such as sample misidentification, inappropriate or inadequate sample collection, sample contamination, as well as the challenges to the diagnostic accuracy of current COVID-19 tests.
ISMP Medication Safety Alert! Acute Care Edition. October 24, 2019.
Automated dispensing cabinets (ADCs) have been implemented in hospitals to improve drug administration safety, but with misuse, can cause patient harm. This newsletter article focuses on three primary ADC user-related problems and offers recommendations for reducing factors that minimize their safe use.
WebM&M Case October 30, 2019
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily).
Schmidt T, Kocher DR, Mahendran P, et al. Stud Health Technol Inform. 2019;267:224-229.
Structured communication methods such as SBAR (situation, background, assessment, recommendation) or ISBAR (identify, situation, background, assessment, recommendation)  were developed to improve handoffs in the hospital, particularly from nursing to physicians, and to reduce the impact of poor communication on adverse events. This study presents a digital pocket card incorporating ISBAR standards that can be used by nurses to facilitate patient handoffs and reporting.
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. BMC Med Inform Decis Mak. 2019;19:174.
There are challenges to identifying and measuring diagnostic errors in healthcare settings. This systematic review found evidence that team meetings, error documentation, and trigger algorithms in various clinical settings may reduce diagnostic errors. The authors also found that while there have been numerous studies on interventions targeting diagnostic errors, few such interventions are being used in clinical settings.
Najafzadeh A, Woodrow N, Thoirs K. Australas J Ultrasound Med. 2019;22:206-213.
Distractions are known to be a significant patient safety issue in many settings. This study examined the impact of distractions during obstetric ultrasounds and sonographers expressed concern that distractions increased false negative screenings and could lead to missed diagnoses.  
Mays JA, Mathias PC. J Am Med Inform Assoc. 2019;26:269-272.
Point-of-care test results are often manually transcribed into the electronic health record, which introduces risks of manual transcription errors. The authors of this study took advantage of a redundant workflow in which point-of-care blood glucose results were uploaded and also manually entered by staff. They estimate that 5 in 1000 manually entered results contain clinically significant transcription errors and call for interfacing point-to-care instruments as a patient safety strategy.
Cornes M, Ibarz M, Ivanov H, et al. Diagnosis (Berl). 2019;6:33-37.
Common blood sample errors, such as mislabeling or patient misidentification, can contribute to diagnostic delays. This review highlights the importance of using open-ended questions to gather information from patients and suggests that specimens be labeled with the patient present to ensure accurate verification. A WebM&M commentary explored problems associated with mislabeled blood samples.
Massalha S, Clarkin O, Thornhill R, et al. Can J Cardiol. 2018;34:827-838.
Decision support tools can help reduce diagnostic uncertainty. Discussing how artificial intelligence can be utilized to inform diagnostic decision making and improve the accuracy of cardiac image interpretation, this review suggests that use of such technology can reduce production pressure and cognitive load for imaging physicians.
Taylor-Phillips S, Jenkinson D, Stinton C, et al. Radiology. 2018;287:749-757.
This retrospective analysis of more than 800,000 mammograms examined the effect of a second review of images. With a second reader, fewer women had to return for more imaging and more cancers were detected, suggesting that double reading may enhance the diagnostic performance of mammography.
Ford EC, Evans SB. Med Phys. 2018;45:e100-e119.
Learning from adverse events is a core component of patient safety improvement. This review explores the application of this concept in radiation oncology, successful practices, and challenges for incident learning system implementation in the specialty.

Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191.

Radiology plays a unique role in the determination of a diagnosis. Cognitive and system elements in radiology can contribute to overuse, diagnostic error, and delays. Articles in this special issue discuss communication, information overload, and uncertainty in radiology and describe projects working toward improving safety of radiological imaging.
Waite S, Scott J, Gale B, et al. AJR Am J Roentgenol. 2017;208:739-749.
Interpretive radiology errors can result in delays that contribute to patient harm. This commentary describes human factors that affect diagnostic accuracy and reviews strategies to address weaknesses at the individual and systems level.
Larcos G, Prgomet M, Georgiou A, et al. BMJ Qual Saf. 2017;26:466-474.
Prior research demonstrates that interruptions in health care can compromise patient safety. In this study, researchers observed interruptions experienced by nuclear medicine technologists in their work environment and found that some interruptions were helpful. In addition, technologists had developed personal strategies to optimize for safety.
Menashe SJ, Iyer RS, Parisi MT, et al. AJR Am J Roentgenol. 2016;207:903-911.
This commentary reviews nine cases involving interpretation errors associated with chest radiographs of children to illustrate common mistakes that can occur in pediatric imaging. Each case concludes with a clinical teaching point for practice improvement.
Lauritzen PM, Andersen JG, Stokke MV, et al. BMJ Qual Saf. 2016;25:595-603.
Repeat interpretation of radiological images is known to yield more accurate diagnosis. Investigators interpreted more than 1000 abdominal CT scans twice and found clinically significant changes on the second read in 14% of cases. The authors suggest that using expert second radiology interpretation may enhance diagnostic accuracy.
Calamante F, Ittermann B, Kanal E, et al. J Magn Reson Imaging. 2016;44:1067-1069.
Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.
Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241510349.
Overuse of diagnostic imaging poses patient safety hazards, particularly for children. This report reviews techniques clinicians can use to discuss risks associated with using radiologic procedures with parents of pediatric patients. The publication includes answers to common questions about various types of tests and tips for enhancing conversations with parents.
Rafiei P, Walser EM, Duncan JR, et al. J Vasc Interv Radiol. 2016;27:695-9.
Most research has focused on developing and implementing checklists in surgical settings. This guideline recommends a set of pre-procedure checklist items and offers rationales for each to help hospitals develop a checklist for use in interventional radiology.