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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 - 16 of 16 Results
Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;30:977-985.
Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.
Cifra CL, Sittig DF, Singh H. BMJ Qual Saf. 2021;30:591-597.
Accurate and timely feedback about patient outcomes can inform and improve future clinical decision-making; however, many barriers exist that prevent effective feedback. This article suggests a sociotechnical approach using information technology (IT) to provide clinician feedback. Feedback sent using the electronic health record can be provided asynchronously, by any member of the care team, and in a structured format to ensure relevance and usefulness.

The Leapfrog Group.

Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially develop educational materials to inform health care organization adoption of diagnostic improvement best practices. Building on that experience, a survey component to complement the Leapfrog annual survey will be developed to enhance measurement and motivate improvement.
Wright B, Lennox A, Graber ML, et al. BMC Health Serv Res. 2020;20:897.
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm. The authors synthesized systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures. The review identified several avenues for improving closed-loop communication through the use of technology, audit and feedback, and use of point-of-care or bedside testing.

Washington DC; National Quality Forum: October 6, 2020.

With input from a stakeholder committee, the National Quality Forum identified recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Measurement Framework  for measuring and improving diagnostic error and patient safety. The committee developed four ‘use cases’ (missed subtle clinical findings; communication failures; information overload; and dismissed patients) reflecting high priority examples of diagnostic error that can result in patient harm. The report includes comprehensive, broad-scope, actionable, and specific recommendations for implementing quality improvement activities to engage patients, educate clinicians, leverage technology, and support a culture of safety with the goal of reducing diagnostic errors. 
Meyer AND, Upadhyay DK, Collins CA, et al. Jt Comm J Qual Patient Saf. 2021;47:120-126.
Efforts to reduce diagnostic error should include educational strategies for improving diagnosis. This article describes the development of a learning health system around diagnostic safety at one large, integrated health care system. The program identified missed opportunities in diagnosis based on clinician reports, patient complaints, and risk management, and used trained facilitators to provide feedback to clinicians about these missed opportunities as learning opportunities. Both facilitators and recipients found the program to be useful and believed it would improve future diagnostic safety. 

Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

Challenges to effective clinical reasoning reduce diagnostic accuracy. This special issue provides background for a new approach to clinical reasoning: situativity. The articles explore the four complementary facets of the concept -- situated cognition; distributed cognition; embodied cognition; and ecological psychology – and describes how situativity can enhance diagnosis through a holistic approach to education, assessment, and research.    
Lippi G, Simundic A-M, Plebani M. Clin Chem Lab Med. 2020;58:1070-1076.
This paper discusses potential vulnerabilities in the laboratory diagnosis of COVID-19, such as sample misidentification, inappropriate or inadequate sample collection, sample contamination, as well as the challenges to the diagnostic accuracy of current COVID-19 tests.
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. BMC Med Inform Decis Mak. 2019;19:174.
There are challenges to identifying and measuring diagnostic errors in healthcare settings. This systematic review found evidence that team meetings, error documentation, and trigger algorithms in various clinical settings may reduce diagnostic errors. The authors also found that while there have been numerous studies on interventions targeting diagnostic errors, few such interventions are being used in clinical settings.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-36.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.
WebM&M Case April 1, 2006
A woman has an intrauterine contraceptive device placed at the time of "her period." A month later it is discovered that she is pregnant, as she had been at the time of the insertion.
WebM&M Case February 1, 2004
A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
WebM&M Case June 1, 2003
Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.