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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 302 Results
WebM&M Case September 29, 2021

A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics.

Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
WebM&M Case August 25, 2021

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;8:525-531.
Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.
WebM&M Case June 30, 2021

Beginning in her teenage years, a woman began "feeling woozy" after high school gym class. The symptoms were abrupt in onset, lasted between 5 to 15 minutes and then subsided after sitting down. Similar episodes occurred occasionally over the following decade, usually related to stress. When she was in her 30s, she experienced a more severe episode of palpitations and went to the emergency department (ED). An electrocardiogram (ECG) was normal and she was discharged with a diagnosis of stress or possible panic attack.

Sinha P, Pischel L, Sofair AN. Diagnosis (Berl). 2021;8:157-160.
Reducing diagnostic error is essential to patient safety. This article describes the use of structured education sessions and deliberate practice with senior clinicians to improve diagnostic skills among medical residents. These sessions focused on generating differential diagnoses and identifying cognitive errors and knowledge gaps.
Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85:27-35.
Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.  
WebM&M Case November 25, 2020

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died.

Skin of Color Society Foundation, NEJM Group, and VisualDx. October 28--December 2, 2020.

Diagnostic decision making can be affected by implicit racial bias. This 4-part series explored tools and techniques to improve diagnosis in patients of color. Topics covered included structural racism, explicit analysis of disease patterns and treatments, cultural competency, and policy improvement.   
Zolnikov T, Zolnikov TR. J Prim Care Community Health. 2020;11:215013272095986.
This commentary describes the challenges of traditional approaches to differential diagnosis during the COVID-19 pandemic. The authors suggest the use of a “bottom-up” approach to diagnosis, which first eliminates the rare and/or serious diagnoses before moving on to more common diagnoses, thereby ensuring that all patients are screened for more serious diseases and improving timely diagnosis.     
Cantey C. J Nurs Pract. 2020;16:582-585.
This article discusses cognitive decision processes and biases, and their consequences on clinical decision making by nurse practitioners. The authors present several clinical examples of diagnostic error and discuss strategies to avoid future errors.
Boyle JG, Walters MR, Jamieson S, et al. Diagnosis (Berl). 2020;7:177-179.
In this Letter to the Editor, the authors suggest that the COVID-19 pandemic presents a unique opportunity to consider how situational factors impact clinical reasoning performance and lead to errors. The authors discuss the potential implications through a clinical story involving a redeployed resident working in a COVID-19 assessment and treatment unit and an older man with respiratory symptoms. 
Schiff GD, Mirica MM. Diagnosis (Berl). 2020;7:377-380.
This commentary discuses key issues related to diagnostic accuracy in the era of COVID-19, including considering differential diagnoses for COVID-19, the challenges of remote diagnoses, and the consequences of lapses in routine diagnostic and preventive care.
Brown L. Diagnosis (Berl). 2020;7:83-84.
This editorial describes one clinician’s experience treating a patient during the early stages of the COVID-19 pandemic, and the impacts of “COVID blindness” and anchoring bias, which resulted in delayed sepsis treatment for this patient.
WebM&M Case July 29, 2020

A 52-year-old woman with a known history of coronary artery disease and ischemic cardiomyopathy was admitted for presumed community-acquired pneumonia. The inpatient medicine team obtained a “curbside” cardiology consultation which concluded that the worsening left ventricular systolic functioning was in the setting of acute pulmonary edema. Two months post-discharge, a nuclear stress test was suggestive of infarction and a subsequent catheterization showed a 100% occlusion.

WebM&M Case July 29, 2020

A 28-year-old woman arrived at the Emergency Department (ED) with back pain, bloody vaginal discharge, and reported she had had a positive home pregnancy test but had not received any prenatal care and was unsure of her expected due date. The ED intern evaluating the patient did not suspect active labor and the radiologist remotely reviewing the pelvic ultrasound mistakenly identified the fetal head as a “pelvic mass.” Four hours later, the consulting OB/GYN physician recognized that the patient was in her third trimester and in active labor.

Platts-Mills TF, Nagurney JM, Melnick ER. Ann Emerg Med. 2020;75:715-720.
Clinicians commonly face uncertainty in complex care situations. The authors propose several strategies for physicians, physician groups, departments, and professional societies to integrate uncertainty into emergency medicine decision-making.