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 102 Results

Diagnostic stewardship to prevent diagnostic error.

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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.

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Diagnostic Errors Case Studies

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. ...

A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis.

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Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;18:833-839.

Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology.

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Clayton DA, Eguchi MM, Kerr KF, et al. Med Decis Making. 2023;43:164-174.

Metacognition (e.g., when one reflects on one’s own decision and decision making) is an approach to reducing diagnostic errors. Using data from the Melanoma Pathology Study (M-PATH) and Breast Pathology Study (B-PATH), researchers assed pathologists’ metacognition by examining their diagnostic accuracy and self-confidence. Results showed pathologists with increased metacognition sensitivity were more likely to request a second opinion for incorrect diagnosis than they were for a correct diagnosis.

Patterns of error in interpretive pathology.

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Packer MDC, Ravinsky E, Azordegan N. Am J Clin Pathol. 2022;157:767-773.

Studies have shown diagnostic discordance in evaluation of surgical pathology specimens. In this study, pathologists and pathology residents were asked to diagnose surgical pathology or cytopathology cases and provide a diagnosis. Most respondents provided the correct diagnosis for most of the cases; 35% of cases were wholly or partially misdiagnosed. Educational and process changes (e.g., requiring subspecialist over-read for some diagnoses) were implemented in the pathology department in response, resulting in substantial improvement in error rates.

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

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Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.

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Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.

Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review.

Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19.

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Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;182:730-738.

Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.

Error and cognitive bias in diagnostic radiology.

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Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.

Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

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Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.

Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.

Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned.

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Lamoureux C, Hanna TN, Sprecher D, et al. Emerg Radiol. 2021;28:1135-1141.

Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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Patient Safety Primer January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

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Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2022;146:886-893.

A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.

Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy.

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Freeman K, Geppert J, Stinton C, et al. BMJ. 2021;374:n1872.

Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice.

Misdiagnosis of acute myocardial infarction: a systematic review of the literature.

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Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.

Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

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Lubin IM, Astles J R, Shahangian S, et al. Diagnosis (Berl). 2021;8:281-294.

Diagnostic error reduction continues to be a patient safety focus. This article outlines innovative ways clinical laboratory professionals can support diagnostic excellence, such as improved communication between laboratory professionals, providers and patients.

A Postpartum Woman with an Erroneous SARS-CoV-2 Test

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WebM&M Case April 28, 2021

A pregnant patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening protocol for SARS-CoV-2. During surgery, the patient developed a fever and required oxygen supplementation. Due to suspicion for COVID-19, a specimen obtained via nasopharyngeal swab was sent to a commercial laboratory for reverse transcriptase polymerase chain reaction (RT-PCR) testing.

Clinical and financial implications of second-opinion surgical pathology review.

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Johnson SM, Samulski TD, O’Connor SM, et al. Am J Clin Pathol. 2021;156:559-568.

Newly diagnosed cancer patients may request second opinions to confirm diagnosis, treatment, or prognosis. This study evaluated the pathology-specific reimbursement for cases originating at the primary site, a comprehensive cancer center, and cases originating at affiliate sites and referred to the cancer center for second opinions. Results confirmed that second opinions can reduce diagnostic errors and potentially lower costs of subsequent treatment; however, ways to improve the cost and process of receiving a second opinion should be explored.

A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist.

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Horowitz SH. Washington Post. October 4, 2020.

The harm of misdiagnosis can be extended by lack of clinician recognition and acceptance of the error when a patient raises concerns. This news story shares the experience of a physician-patient whose recognition of a diagnostic mistake was initially dismissed. The author defines the repeated lack of organizational willingness to resolve the situation as a normalized deviance in health care.

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