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 44 Results

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.

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.

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.

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.

Anesthesia outside of the OR: cause for patient safety concerns?

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DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.

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.

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

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Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.

Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

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Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA Oncol. Epub 2022 Apr 21.

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.

Quality Special Issue.

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J Med Imaging Radiat Oncol. 2022;66(2):165-309.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

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Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.

Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.

Delayed Diagnosis of Kidney Transplant Complications

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WebM&M Case February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

Preventing and mitigating radiology system failures: a guide to disaster planning.

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Gibney BT, Roberts JM, D'Ortenzio RM, et al. RadioGraphics. 2021;41:2111-2126.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

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Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;68:356-363.

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

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Yonash RA, Taylor M. Patient Safety. 2020;2:24-39.

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

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Khalatbari H, Menashe SJ, Otto RK, et al. Pediatr Radiol. 2020;50:1409-1420.

This study reviewed safety events involving diagnostic or interventional radiology at one children’s hospital and used data from the root cause analyses to characterize the contributing system failures and key activities and processes. Approximately one-quarter of the safety events were secondary to diagnostic errors. The most common key processes involved in these events were diagnostic and procedural services, and the most common key activities were interpreting/analyzing and coordinating activities.

Radiation Safety

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Patient Safety Primer September 7, 2019

Greater availability of advanced diagnostic imaging techniques has resulted in tremendous benefits to patients. However, the increased use of diagnostic imaging poses significant harm to patients through excessive exposure to ionizing radiation.

Patient safety in medical imaging: a joint paper of the European Society of Radiology (ESR) and the European Federation of Radiographer Societies (EFRS).

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Radiology ES of, Societies EF of R. Insights Imaging. 2019;10:45.

Numerous factors affect safe imaging practice, including potential harms associated with radiation, staffing demands, and patient physical and psychological well-being. This policy statement provides multidisciplinary insights on safety themes in radiology that go beyond the core concern of inappropriate radiation exposure. The authors recommend tactics to reduce the risks related to data protection, service environment, teamwork, burnout, and training.

Which Line: Ordering Provider or Proceduralist?

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WebM&M Case March 1, 2019

A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.

Performing an inadvertent procedure.

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Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.

The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.

Creating a culture of accountability promotes safe medical care.

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Canadian Medical Protective Association; CMPA.

Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.

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