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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 325 Results
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.
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.
Richman IB, Long JB, Soulos PR, et al. Ann Intern Med. 2023;176:1172-1180.
Overdiagnosis can result in overtreatment, physical harm, and emotional distress. Using SEER-Medicare data, researchers examined breast cancer overdiagnosis by comparing cancer incidence among women who discontinued mammography screening after age 70 compared to women who continued to receive screening mammograms. Findings suggest that breast cancer may be potentially overdiagnosed among 31% of women aged 70 to 74 years, 47% of women aged 75 to 84 years, and 54% of women aged 85 and older who continue to receive screening mammograms.

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.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, six sigma, and high reliability organizations.
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Hovda T, Larsen M, Romundstad L, et al. Eur J Radiol. 2023;165:110913.
Timely cancer diagnosis remains an important area for improvement. Using a national breast cancer registry, researchers reread negative screening mammograms of women diagnosed with breast cancer in the two years following the screening. Screening mammograms were then rated as true negative (i.e., no cancer could be detected) or missed (i.e., signs of cancer were visible but missed). Among women with screen-detected or interval cancer, most initial screening mammograms did not show visible signs of cancer.
WebM&M Case June 28, 2023

During an elective diagnostic cardiac catheterization, the cardiologist unintentionally perforated the patient’s left ventricular wall with the catheter. The cardiologist failed to recognize the perforation, failed to take corrective measures to address the problem, and continued with the cardiac catheterization, including coronary angiographic imaging. Soon after the end of the procedure, the patient complained of severe chest pain and echocardiographic images revealed bleeding around the heart caused by the catheter-related ventricular wall perforation.

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.
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.
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.

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.
Curated Libraries
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. ...
Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Michelle Schreiber photograph

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

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. 

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.
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.
WebM&M Case October 27, 2022

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.

Curated Libraries
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.