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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 137 Results
Kaplan HM, Birnbaum JF, Kulkarni PA. Diagnosis (Berl). 2022;9:421-429.
Premature diagnostic closure, also called anchoring bias, relies on initial diagnostic impression without continuing to explore differential diagnoses. This commentary proposes a cognitive forcing strategy of “endpoint diagnosis,” or continuing to ask “why” until additional diagnostic evaluations have been exhausted. The authors describe four common contexts when endpoint diagnoses are not pursued or reached.
Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Li E, Clarke J, Ashrafian H, et al. J Med Internet Res. 2022;24:e38144.
Electronic health records (EHR) systems frequently interact with EHRs in other organizations, between clinical settings (e.g., in-patient and out-patient), or with devices (e.g., smart pumps). In this review, 12 studies were identified that examined the effect of EHR interoperability on patient safety. While EHR interoperability was shown to improve patient safety, outcome measure heterogeneity limits measuring true effects.
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.
WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.
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.

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.
Meyer AND, Scott TMT, Singh H. JAMA Netw Open. 2022;5:e228568.
Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.
WebM&M Case March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

Domingo J, Galal G, Huang J. NEJM Catalyst. 2022;3.
Failure to follow up on abnormal diagnostic test results can cause delays in patients receiving appropriate care. This hospital used an artificial intelligence natural language processing system to identify radiology reports requiring follow-up. The system triggered automated notifications to the patient and ordering provider, and tracked follow-ups to completion. System development, deployment and next steps are detailed.
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.
Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21:618.
Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.
Montaleytang M, Correard F, Spiteri C, et al. Int J Clin Pharm. 2021;43:1183-1190.
Previous studies have found that discrepancies between patients’ medication lists and medications they are actually taking are common. This study found that sharing the results of medication reconciliation performed at admission and discharge with patients’ community care providers led to a decrease in medication discrepancies.
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.
Carman E-M, Fray M, Waterson P. Appl Ergon. 2021;93:103339.
This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include  improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.