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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 190 Results
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.  
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.
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.

Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;18:833-839.
Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.
Clayton DA, Eguchi MM, Kerr KF, et al. Med Decis Making. 2023;43:164-174.
Metacognition (e.g., when one reflects on one’s own decision and decision making) is an approach to reducing diagnostic errors. Using data from the Melanoma Pathology Study (M-PATH) and Breast Pathology Study (B-PATH), researchers assed pathologists’ metacognition by examining their diagnostic accuracy and self-confidence. Results showed pathologists with increased metacognition sensitivity were more likely to request a second opinion for incorrect diagnosis than they were for a correct diagnosis.
Perspective on Safety September 28, 2022

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

Perspective on Safety September 28, 2022

Jack Westfall, MD MPH, is a retired professor from the University of Colorado School of Medicine and Former Director of the Robert Graham Center. We spoke with him about the role of primary care in the health and well-being of individuals, the hallmarks of high quality primary care and opportunities of primary care providers to enhance or promote patient safety.

WebM&M Case August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.

Perspective on Safety August 5, 2022

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;48:492-496.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.

Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

 Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.
Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.
Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review. 
Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Nehls N, Yap TS, Salant T, et al. BMJ Open Qual. 2021;10:e001603.
Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.
Rajan SS, Baldwin JL, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.
Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
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.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.