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 29 Results

Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medical center: a case-control study.

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Ivanovic V, Broadhead K, Beck R, et al. AJR Am J Roentgenol. 2023;221:355-362.

Like many clinical areas, a variety of system factors can influence diagnostic error rates in neuroradiology. This study included 564 neuroradiologic examinations with diagnostic error and 1,019 without error. Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend interpretation.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

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Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.

Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Perceptions of radiation safety culture in medical imaging by role.

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Moore QT, Haynes KW. Radiol Technol. 2023;94(5):337-347.

Fostering a culture of safety is a core patient safety objective. This survey of 425 radiologic technologists explored differences in radiation safety culture between staff technologists and those in leadership roles. Findings identified several positional hierarchical imbalances in perceived determinants of safety culture, which could hinder efforts to establish a just culture and a positive organizational radiation safety culture.

Developing electronic clinical quality measures to assess the cancer diagnostic process.

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Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.

Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.

Reducing errors resulting from commonly missed chest radiography findings.

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Gefter WB, Hatabu H. Chest. 2023;163:634-649.

Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

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.

Reducing diagnostic errors in the emergency department at the time of patient treatment.

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Petts A, Neep M, Thakkalpalli M. Emerg Med Australas. 2023;35:466-473.

Misinterpretation of radiology test results can contribute to diagnostic errors and patient harm. Using a set of 838 pediatric and adult radiographic examinations, this retrospective study found that radiographers’ interpretations can complement emergency clinicians’ interpretations and increase accuracy compared to emergency clinician interpretation alone.

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.

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