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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 25 Results
Krevat S, Samuel S, Boxley C, et al. JAMA Netw Open. 2023;6:e238399.
The majority of healthcare providers use electronic health record (EHR) systems but these systems are not infallible. This analysis used closed malpractice claims from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error, the types of errors, and where in the diagnostic process errors occur. EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the testing stage.
Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19:211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims with at least one diagnostic error were analyzed. No singular factor was identified; instead multiple contributing factors were implicated along the diagnostic pathway.
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18:1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.
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, collaborative initiatives, teamwork, and trigger tools.
Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3:221-230.
This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.
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.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24:185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).

Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.  

The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).  
Reaume M, Farishta M, Costello JA, et al. Postgrad Med J. 2020;97:55-58.
Point-of-care ultrasounds (POCUS) are considered a powerful tool to enhance patient safety through expedited diagnosis, but also present safety threats. There is a concern that POCUS use may contribute to diagnostic error lawsuits. The authors reviewed lawsuits involving the diagnostic use of POCUS in internal medicine, pediatrics, family medicine, and critical care and did not find any cases of physicians in these specialties being subject to adverse legal action for the diagnostic use of POCUS.   
Kravet SJ, Bhatnagar M, Dwyer M, et al. J Patient Saf. 2019;15:e98-e101.
Few models for systematically targeting patient safety risks in large health systems exist. For this quality improvement study encompassing five large health care delivery systems, key informants were interviewed at seven affiliated outpatient sites in an effort to understand why ambulatory care accounted for 30-35% of annual medical malpractice costs and missed or delayed diagnoses comprised about 50% of liability risk associated with office practices. Analysis revealed eight common patient safety risk domains; the single most important was communication and follow-up of diagnostic test results. The authors recommend employing their targeted approach to safety improvements in other large health systems.   
Aaronson E, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019;39:19-29.
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.
Khoong EC, Cherian R, Rivadeneira NA, et al. Health Aff (Millwood). 2018;37:1760-1769.
California's Medicaid pay-for-performance program requires safety-net health care systems to report and improve upon diverse ambulatory safety measures. Researchers found that participating safety-net hospitals struggled to report accurate data. Systems had more success improving metrics that placed patients at risk of life-threatening harm when compared to metrics that required longer term follow-up or patient engagement.
Schiff G, Nieva HR, Griswold P, et al. Health Serv Res. 2016;51 Suppl 3:2634-2641.
Prior research has shown that malpractice risk in the outpatient setting is significant and that claims frequently involve missed and delayed diagnoses. This editorial describes lessons learned from the Massachusetts PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) project. Funded by the Agency for Healthcare Research and Quality, the PROMISES project involved a multipronged intervention within 16 randomly selected primary care practices to address known areas of risk in ambulatory care, including test result management, referrals, medication management, and communication issues. A previous PSNet perspective discussed how research may help improve the malpractice system.
Arbaje AI, Werner NE, Kasda EM, et al. J Patient Saf. 2020;16:52-57.
Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.
Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
In response to a recent investigation raising concerns about inaccurate reporting of wait-time data, this commentary relates barriers to improving patient safety, such as overuse of performance measures. The authors describe approaches to augment safety, such as narrowing down performance measures to address the most significant concerns and engaging private health care organizations in improvement projects.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22:672-680.
The patient safety consequences of diagnostic errors have been receiving greater attention in the past few years, after being relatively neglected in the early period of the safety movement. The results of this study will likely add momentum to this "next frontier" in patient safety. The authors analyzed 25 years of closed malpractice claims from the National Practitioner Data Bank and found that diagnostic errors—primarily in the outpatient setting—were both the most common and the most costly (in terms of total payments) type of claim. Compared with other types of errors, diagnostic errors were more likely to result in serious patient harm or death. Although data from closed malpractice claims may not be representative of all error types, it is clear from this study that diagnostic errors account for a large proportion of preventable patient harm. Recent reviews have identified strategies to improve diagnostic accuracy at the individual clinician level and at the system level. The human costs of a fatal diagnostic error—for the patient and the clinician—were vividly illustrated in a recent graphic-novel style article.
Shermock KM, Streiff MB, Pinto BL, et al. J Thromb Haemost. 2011;9:1769-1775.
In this study, investigators compared international normalized ratio measurements (INR, a measurement of blood clotting ability) obtained simultaneously on a point-of-care analyzer and a standard blood draw. Although the concordance between the two measurements met traditional quality assurance standards, the point-of-care analyzer results were systematically biased toward normal measurements, putting patients at risk of preventable adverse events due to failure to adjust anticoagulant medications appropriately.