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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 127 Results

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

Save to Library

Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.

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.

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Save to Library

Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room.

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.

Patient Safety in the Ambulatory Care Setting

Save to Library

Perspective on Safety August 5, 2022

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed.

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study.

Save to Library

Watson J, Salisbury C, Whiting PF, et al. Br J Gen Pract. 2022;72:e747-e754.

Failure to communicate blood test results to patients may result in delayed diagnosis or treatment. In this study, UK primary care patients and general practitioners (GPs) were asked about their experiences with the communication of blood test results. Patients and GPs both expected the other to follow up on results and had conflicting experiences with the method of communication (e.g., phone call, text message).

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

Save to Library

Meyer AND, Scott TMT, Singh H. JAMA Netw Open. 2022;5:e228568.

Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.

When no news is bad news: improving diagnostic testing communication through patient engagement.

Save to Library

Zomerlei T, Carraher A, Chao A, et al. J Patient Saf Risk Manage. 2021;26:221-224.

Failure to communicate abnormal test results to patients can lead to significant health complications and medical malpractice claims. This study aimed to increase patient engagement in asking their provider about previously obtained diagnostic test results. Reminders to follow up with their provider about test results were sent to the patient via the after-visit summary and patient portal. Patients receiving reminders were up to 20 times more likely to ask their providers about their test results, compared to patients who did not receive reminders.

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

Save to Library

Rajan SS, Baldwin J, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.

Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

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

Save to Library

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.

Application of human factors methods to understand missed follow-up of abnormal test results.

Save to Library

Rogith D, Satterly T, Singh H, et al. Appl Clin Inform. 2020;11:692-698.

Lack of timely follow-up of test results is a recognized patient safety problem in primary care and can lead to missed or delayed diagnoses. This study used human factors methods to understand lack of timely follow-up of abnormal test results in outpatient settings. Through interviews with the ordering physicians, the researchers identified several contributing factors, such as provider-patient communication channel mismatch and diffusion of responsibility.

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

Save to Library

Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.

This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.

Pre-analytical pitfalls: Missing and mislabeled specimens

Save to Library

WebM&M Case February 26, 2020

This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.

Advancing safety with closed-loop communication of test results.

Save to Library

Quick Safety. December 17, 2019;(52):1-3.

Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares recommendations to enhance handoffs and information sharing amongst care teams and with patients.

Error Reduction and Prevention in Surgical Pathology, Second Edition.

Save to Library

Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.

Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.

Implementation and evaluation of a laboratory safety process improvement toolkit.

Save to Library

Kwan BM, Fernald D, Ferrarone P, et al. J Am Board Fam Med. 2019;32:136-145.

This qualitative evaluation found that the AHRQ Improving Your Office Testing Process toolkit was perceived as usable and applicable to the clinical setting. The content for patient engagement and communication with test results was particularly valued.

Building an ambulatory safety program at an academic health system.

Save to Library

Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.

Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.

Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

Save to Library

Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.

Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.

Reducing diagnostic errors worldwide through diagnostic management teams.

Save to Library

Verna R, Velazquez AB, Laposata M. Ann Lab Med. 2019;39:121-124.

Teamwork in health care has been embraced as a key element of patient safety. This review highlights the value of creating diagnostic management teams tasked with selecting laboratory tests and interpreting test results to improve diagnostic safety. The authors highlight the potential to apply this strategy to health systems worldwide to enhance communication, efficiency, and accuracy.

Measuring the rate of manual transcription error in outpatient point-of-care testing.

Save to Library

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.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site