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 22 Results

Common and consequential fractures that should not be missed in children.

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Tougas C, Brimmo O. Pediatr Ann. 2022;51:e357-e363.

Diagnostic errors involving pediatric musculoskeletal radiographs can lead to adverse patient safety outcomes. This article discusses contributing factors to missed or delayed diagnosis of pediatric fractures and strategies to improve diagnosis.

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

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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.

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

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Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.

Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

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Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.

Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.

An evolution of reporting: identifying the missing link.

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Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.

Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.

Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians.

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Li W, Stimec J, Camp M, et al. J Emerg Med. 2022;62:524-533.

While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.

Medication Safety Events Related to Diagnostic Imaging

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WebM&M Case July 8, 2022

This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.

Mandating limits on workload, duty, and speed in radiology.

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Alexander R, Waite S, Bruno MA, et al. Radiology. 2022:212631.

To reduce medical errors caused by fatigue, the Accreditation Council for Graduate Medical Education (ACGME) adopted duty hour restrictions for ACGME-accredited residency programs; however, other healthcare fields have not yet done so. This review presents the limited existing evidence for regulating duty hours for radiologists and proposes that additional research needs to be completed before implementing restrictions.

Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up.

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Domingo J, Galal G, Huang J. NEJM Catalyst. 2022;3.

Failure to follow up on abnormal diagnostic test results can cause delays in patients receiving appropriate care. This hospital used an artificial intelligence natural language processing system to identify radiology reports requiring follow-up. The system triggered automated notifications to the patient and ordering provider, and tracked follow-ups to completion. System development, deployment and next steps are detailed.

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.

Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic accuracy.

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Alexander RG, Yazdanie F, Waite S, et al. Front Neurosci. 2021;15:629469.

Incorrect interpretation of radiologic images can result in delayed diagnosis or unneeded additional tests and treatment. This commentary describes the visual illusions radiologists use in detecting and categorizing abnormalities, and recommends further research into the ways visual illusions are used in order to improve diagnostic safety.

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

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Brown SD. Pediatr Radiol. 2021;51:1070-1075.

Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.

Pediatric chest radiographs: common and less common errors.

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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.

Diagnostic delays in paediatric stroke.

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Mallick AA, Ganesan V, Kirkham FJ, et al. J Neurol Neurosurg Psychiatry. 2015;86:917-21.

Diagnostic error is a rapidly growing area of patient safety research, especially in light of the recent release of the National Academy of Medicine report on improving diagnosis. This study explored diagnostic delays for children with strokes and found significant delays at each step of the process, particularly following a nondiagnostic CT scan. The authors advocate for obtaining an MRI expeditiously in any suspected case of arterial ischemic stroke in a child.

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites.

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Bisset GS, Crowe J. Pediatr Radiol. 2014;44:552-7.

This study found that diagnostic errors in interpretation of pediatric musculoskeletal radiographs were relatively rare, occurring in 2.7% of cases. The majority of errors involved false negative readings (i.e., missed injuries).

Safety in Radiology

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Perspective on Safety October 1, 2013

This piece explores how to mitigate risks associated with radiology procedures.

Improving team performance during the preprocedure time-out in pediatric interventional radiology.

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Gottumukkala R, Street M, Fitzpatrick M, et al. Jt Comm J Qual Patient Saf. 2012;38:387-94.

Audiovisual recordings, reviews, continual feedback, and modifications led to significant improvements in team performance of pre-procedure time outs.

Diagnostic errors in pediatric radiology.

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Taylor GA, Voss SD, Melvin PR, et al. Pediatr Radiol. 2011;41:327-34.

Analysis of 265 errors in radiologic diagnosis was used to develop a taxonomy for diagnostic error in pediatric radiology.

Image Gently, Step Lightly: promoting radiation safety in pediatric interventional radiology.

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Sidhu M, Goske MJ, Connolly B, et al. AJR Am J Roentgenol. 2010;195:W299-301.

This commentary describes a checklist initiative to standardize workflow, promote team responsibility, and improve the safety of pediatric radiology procedures.

Improving patient safety: effects of a safety program on performance and culture in a department of radiology.

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Donnelly LF, Dickerson JM, Goodfriend MA, et al. AJR Am J Roentgenol. 2009;193:165-71.

This study found that implementation of a comprehensive and multifaceted safety program improved reports of safety culture among pediatric radiologists.

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