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 330 Results

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study.

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Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.

Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

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Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.

Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.

Radiologist age and diagnostic errors.

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Lamoureux C, Hanna TN, Callaway E, et al. Emerg Radiol. 2023;30:577-587.

Clinician skills can decrease with age. This retrospective analysis of 1.9 million preliminary interpretations of radiology imaging findings examined the relationship between radiologist age and diagnostic errors. While the overall mean error rate for all radiologists was low (0.5%), increasing age was associated with increased relative risk of diagnostic errors.

Cross-Check QA: a quality assurance workflow to prevent missed diagnoses by alerting inadvertent discordance between the radiologist and AI in the interpretation of high acuity CT scans.

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Chekmeyan M, Baccei SJ, Garwood ER. J Am Coll Radiol. 2023;Epub Jul 7.

Artificial intelligence (AI) has become a useful tool to support radiologists in diagnostic imaging. In this study, discordant findings between the radiologist and AI (negative by radiologist report, positive by AI report, with unviewed AI decision support system output) triggered an automatic manual review of the diagnostic images. More than 111,000 CT studies were analyzed, with 46 triggering the automatic review; of those, 26 (0.02%) were true positives (i.e., missed diagnosis by radiologist but identified by AI).

Effects of work shift or shift length on radiation safety perception.

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Moore QT, Bruno MA. Radiol Technol. 2023;94(6):409-418.

Fostering a culture of safety is a key objective across all clinical areas, including radiology. This secondary analysis of survey data found that radiologists working night shifts and shifts exceeding 12 hours have poor perceptions of teamwork and of leadership actions concerning radiation safety.

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.

Estimating breast cancer overdiagnosis after screening mammography among older women in the United States.

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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.

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.

Quality and Safety in Health Care.

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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.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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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.

Breast cancer missed at screening; hindsight or mistakes?

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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.

Ventricular Wall Injury during a Diagnostic Cardiac Catheterization

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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.

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.

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.

Curated Libraries

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. ...

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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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.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

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.

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