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Patient Safety Network

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 1462 Results
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    • Electronic health record use issues and diagnostic error: a scoping review and framework.
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    • Dixit RA, Boxley CL, Samuel S, et al. J Patient Saf. 2023;19:e25-e30.
    Electronic health records (EHR) may have unintended negative consequences on patient safety. This review identified 11 articles focused on the relationship between EHR use and diagnostic error. EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation and communication. The majority of issues were a related to providers’ cognitive processing, revealing an important area of research and quality improvement.
    ER doctors misdiagnose patients with unusual symptoms.
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    • Abelson R. New York Times. December 15, 2022.

    Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.
    Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes.
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    • Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.
    Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.
    Quality and Safety in Health Care.
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    • Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

    This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
    How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.
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    • Zigman Suchsland M, Kowalski L, Burkhardt HA, et al. Cancers (Basel). 2022;14:5756.
    Delayed diagnosis and treatment of cancer is a serious patient safety problem. This retrospective study including 711 patients diagnosed with lung cancer used electronic health records and natural language processing (NLP) to identify relevant signs and symptoms in the two years prior to their cancer diagnosis. Researchers found that NLP can identify signs and symptoms associated with lung cancer over a year prior to diagnosis.
    Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study.
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    • Svedahl ER, Pape K, Austad B, et al. BMJ Qual Saf. 2022;Epub Dec 15.
    Inappropriate referrals and unnecessary hospital admissions are ongoing patient safety problems. This cohort study set in Norway examined the impact of emergency physician referral thresholds from out-of-hours services on patient outcomes.  
    Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.
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    • Cohen AL, Sur M, Falco C, et al. Diagnosis (Berl). 2022;9:476-484.
    Clinical reasoning is now a common method to improve diagnostic decision making, and several tools have been developed to assess learners’ clinical reasoning. In this study, hospital faculty and pediatric interns used the Assessment of Reasoning Tool (ART) to assess, teach, and guide feedback on the interns’ clinical reasoning. Faculty and interns report the ART framework was highly structured, specific, formative, and facilitated goal setting.
    Diagnostic Errors in the Emergency Department: a Systematic Review.
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    • Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

    Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures. 
    Structural racism and adverse maternal health outcomes: a systematic review.
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    • Hailu EM, Maddali SR, Snowden JM, et al. Health Place. 2022;78:102923.
    Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.
    Cohort study of diagnostic delay in the clinical pathway of patients with chronic wounds in the primary care setting.
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    • Ahmajärvi K, Isoherranen K, Venermo M. BMJ Open. 2022;12:e062673.
    Diagnostic errors continue to be a source of patient harm. This retrospective study identified patient- and organizational-level factors contributing to misdiagnosis of chronic wounds in primary care. Less than half of patients referred from primary care to specialist wound care teams had the correct diagnosis. Notably, 36% of patients who presented to primary care had signs of infection, however 61% received antibiotics, raising concerns of antibiotic overuse.
    Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
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    • WebM&M Case December 14, 2022

    This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic testing. The patient was admitted to the hospital with gastrointestinal symptoms and diagnosed with cholecystitis and gangrenous gallbladder. Two months after his admission for cholecystitis, he was readmitted for severe vomiting and hypotension.

    Using community detection techniques to identify themes in COVID-19-related patient safety event reports.
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    • Boxley C, Krevat SA, Sengupta S, et al. J Patient Saf. 2022;18:e1196-e1202.
    COVID-19 changed the way care is delivered to hospitalized patients and resulted in new categories and themes in patient safety reporting. This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors, pressure ulcers, and falls.
    A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.
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    • Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
    Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
    Complexity and challenges of the clinical diagnosis and management of Long COVID.
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    • O’Hare AM, Vig EK, Iwashyna TJ, et al. JAMA Netw Open. 2022;5:e2240332.
    Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.
    Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews.
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    • Sibbald M, Abdulla B, Keuhl A, et al. JMIR Hum Factors. 2022;9:e39234.
    Electronic differential diagnostic support (EDS) are decision aids that suggest one or more differential diagnoses based on clinical data entered by the clinician. The generated list may prompt the clinician to consider additional diagnoses. This study simulated the use of one EDS, Isabel, in the emergency department to identify barriers and supports to its effectiveness. Four themes emerged. Notably, some physicians thought the EDS-generated differentials could reduce bias while others suggested it could introduce bias.
    Mechanical Prosthetic Valve Thrombosis with Thromboembolism.
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    • WebM&M Case November 16, 2022

    A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

    Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.
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    • National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333. 

    The care of older adult patients can be complicated due to comorbidities, bias and polypharmacy. This publication reports on a session that examined diagnostic challenges unique to the older adult population. The existing evidence base and strategies for the future are reviewed.
    Cognitive biases encountered by physicians in the emergency room.
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    • Kunitomo K, Harada T, Watari T. BMC Emerg Med. 2022;22:148.
    Cognitive biases can impede diagnostic decision-making and contribute to diagnostic delays and patient harm. This study explored the types of cognitive biases contributing to diagnostic errors in emergency rooms in Japan. The most common biases reported were overconfidence, confirmation bias, availability bias, and anchoring bias. Findings indicate that most diagnostic errors involved overlooking another disease in the same organ group or related organ (e.g., diagnosing headache rather than stroke).
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