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.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Kostopoulou O, Tracey C, Delaney BC. J Am Med Inform Assoc. 2021;28:1461-1467.
In addition to being used for patient-specific clinical purposes, data within the electronic health record (EHR) may be used for other purposes including epidemiological research. Researchers in the UK developed and tested a clinical decision support system (CDSS) to evaluate changes in the types and number of observations that primary care physicians entered into the EHR during simulated patient encounters. Physicians documented more clinical observations using the CDSS compared to the standard electronic health record. The increase in documented clinical observations has the potential to improve validity of research developed from EHR data.
Zwaan L, El-Kareh R, Meyer AND, et al. J Gen Intern Med. 2021;36:2943-2951.
Reducing harm related to diagnostic error remains a major focus within patient safety. Based on input from an international group of experts and stakeholders, the authors identified priority questions to advance diagnostic safety research. High-priority areas include strengthening teamwork factors (such as the role of nurses in diagnosis), addressing system factors, and strategies for engaging patients in the diagnostic process.
Zhou Y, Walter FM, Singh H, et al. Cancers (Basel). 2021;13:156.
Delays in cancer diagnosis can lead to treatment delays and patient harm. This study linking primary care and cancer registry data found that more than one-quarter of bladder and kidney cancer patients presenting with fast-tract referral features did not achieve a timely diagnosis. These findings suggest inadequate adherence to guidelines intended to help identify patients with high risk of cancer based on the presence of alarm signs and symptoms.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Delvaux N, Piessens V, Burghgraeve TD, et al. Implement Sci. 2020;15:100.
Clinical decision support systems (CDSS) and computerized physician order entry (CPOE) have the potential to improve patient safety. This randomized trial evaluated the impact of integrating CDSS into CPOE among general practitioners in Belgium. The intervention improved appropriateness and decreased volume of laboratory test ordering and did not show any increases in diagnostic errors.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
Elliott J, Williamson K. Radiography. 2020;26:248-253.
Extended work shifts for nurses and physicians have been linked to increased risk of errors. In this systematic review, the authors discuss the impact of shift work disorder on errors and safety implications for radiographers. Studies suggested a positive correlation between errors and increased mental and physical fatigue resulting from shift work or rapid shift rotation, however none of the identified studies focused specifically on radiology professionals.
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.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period. Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care. The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Isbell LM, Boudreaux ED, Chimowitz H, et al. BMJ Qual Saf. 2020;29:815–825.
Research has suggested that health care providers’ emotions may impact patient safety. These authors conducted 86 semi-structured interviews with emergency department (ED) nurses and physicians to better understand their emotional triggers, beliefs about emotional influences on patient safety, and emotional management strategies. Patients often triggered both positive and negative emotions; hospital- or systems-level factors primarily triggered negative emotions. Providers were aware that negative emotions can adversely impact clinical decision-making and place patients at risk; future research should explore whether emotional regulation strategies can mitigate these safety risks.
Matulis JC, Kok SN, Dankbar EC, et al. Diagnosis. 2020;7:107-114.
A brief survey of two internal medicine practices explored clinician perceptions of individual- and systems-level factors contributing to diagnostic errors. The most commonly reported individual-level factors contributing to diagnostic error was atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). Common systems-level contributors identified were cognitive burden associated with the electronic health record system (68%), inadequate time (64%) and lack of collaboration (40%).
Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT-HS-20-004.
This announcement highlights AHRQ continued interest in research regarding the development of an evidence base on the incidence of diagnostic error, its presence in a variety of health care environment and its impact on patient outcomes.
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