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 395 Results

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

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Flemming DJ, White C, Fox E, et al. Skeletal Radiol. 2023;52:493-503.

Radiologic diagnostic errors can result in delayed or unnecessary treatment. This paper describes five types of cognitive biases, with accompanying case study and images, that result in misdiagnosis. Both individual education and system-level solutions are described.

Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update.

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Moran JM, Bazan JG, Dawes SL, et al. Pract Radiat Oncol. 2023;13:203-216.

Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.

Cancer drug shortages are creating dire circumstances for some patients.

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Lovelace B, Jr, Kopf M. NBC. April 11, 2023.

Shortages of life-saving cancer drugs have been a problem for many years and were exacerbated by the COVID-19 pandemic. This news article reports that low profitability of manufacturing generic drugs contributes to this shortage. Until these cancer drugs are available, many patients will receive no treatment, or treatment that is less than ideal.

Early diagnosis of cancer: systems approach to support clinicians in primary care.

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Black GB, Lyratzopoulos G, Vincent CA, et al. BMJ. 2023;380:e071225.

Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.

"We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women.

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Washington A, Randall J. J Racial Ethn Health Disparities. 2023;10:883-891.

Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.

Using A.I. to detect breast cancer that doctors miss.

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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.

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

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Buja A, De Luca G, Ottolitri K, et al. J Pharm Policy Pract. 2023;16:9.

Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying and preventing potential error risks. Using FMECA, public health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure mode in cancer treatment prescription and administration. Each phase of the cancer treatment process had at least one critical step identified, and actions were developed to reduce the likelihood of the error occurring and/or to increase the likelihood of the error being detected.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; February 8, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities is April 18, 2023.

The impact of medication reconciliation and review in patients using oral chemotherapy.

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Darcis E, Germeys J, Stragier M, et al. J Oncol Pharm Pract. 2023;29:270-275.

Medication errors are common in patients using oral chemotherapy. In this study, a hospital pharmacist identified medication discrepancies in nearly 75% of patients starting oral chemotherapy, with an average of two discrepancies per patient. The pharmacist followed up with the patient’s oncologist via the electronic health record, and the oncologist could accept or reject the pharmacist’s recommendation. Patient outcomes were not evaluated in this study.

Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses.

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Maierhofer CN, Ranapurwala SI, DiPrete BL, et al. Drug Alcohol Depend. 2023;242:109727.

A national focus on reducing opioid misuse and abuse has resulted in changes to opioid prescribing policies and practice. This retrospective longitudinal study explored changes in prescribing rates, supply and dose of opioid prescriptions after changes in opioid prescribing policies in North Carolina. Researchers found that that prescribing patterns for acute and postsurgical pain patients (but not chronic pain patients) decreased after a state medical board initiative to reduce high-dose and high-volume. Further, new legislation to limit initial opioid prescriptions for acute and postsurgical pain led to a decrease in prescribing for cancer patients with chronic pain, but did not lead to reductions among patients with acute, postsurgical, or non-cancer chronic pain.

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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. ...

AHRQ Safety Program for Telemedicine.

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Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023.

How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.

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Zigman Suchsland M, Kowalski L, Burkhardt HA, et al. Cancers (Basel). 2022;14:5756.

Delayed diagnosis and treatment of cancer is a serious patient safety problem. This retrospective study including 711 patients diagnosed with lung cancer used electronic health records and natural language processing (NLP) to identify relevant signs and symptoms in the two years prior to their cancer diagnosis. Researchers found that NLP can identify signs and symptoms associated with lung cancer over a year prior to diagnosis.

What do patients and their carers do to support the safety of cancer treatment and care? A scoping review.

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Tillbrook D, Absolom K, Sheard L, et al. J Patient Saf. 2022;18:779-787.

Patient and caregiver engagement in medical treatment can promote safety. This scoping review explored the qualitive research regarding how patients and caregivers engage in safety during cancer treatment. Four themes were identified – patient perception and involvement in safety; patient engagement in their care; safety as a collective responsibility; and the importance of caregivers relative to the amount of support they receive.

Factors impacting on patient setup analysis and error management during breast cancer radiotherapy.

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Costin I-C, Marcu LG. Crit Rev Oncol Hematol. 2022;178:103798.

Radiotherapy errors can be significant and sometimes fatal. This systematic review describes errors in patient set up based on verification systems, the immobilization devices used, and the patient’s positioning during breast cancer treatment. The advantages and drawbacks of the most common position verification systems, error types associated with immobilization systems, and the influence of treatment position are reviewed.

The impact of COVID-19 workflow changes on radiation oncology incident reporting.

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Volpini ME, Lekx‐Toniolo K, Mahon R, et al. J Appl Clin Med Phys. 2022;23:e13742.

The COVID-19 pandemic dramatically impacted the way that health care teams function. This study examined how COVID-19-related workflow changes affected reporting of medical errors and near misses occurring in one hospital’s radiation oncology program. After the onset of the COVID-19 pandemic, there was fewer incidents reported overall, but an increase in submissions related to poor documentation and communication.

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.

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records.

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Wiering B, Lyratzopoulos G, Hamilton W, et al. BMJ Qual Saf. 2022;31:579-589.

Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year.

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

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Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;18:e1181-e1188.

Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites.

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Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.

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