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.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Yale S, Cohen S, Bordini BJ. Crit Care Clin. 2022;38:185-194.
A broad differential diagnosis can limit missed diagnostic opportunities. This article outlines how diagnostic timeouts, which are intended reduce bias during the identification of differential diagnoses, can improve diagnosis and reduce errors.
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...
Meyer AND, Upadhyay DK, Collins CA, et al. Jt Comm J Qual Patient Saf. 2021;47:120-126.
Efforts to reduce diagnostic error should include educational strategies for improving diagnosis. This article describes the development of a learning health system around diagnostic safety at one large, integrated health care system. The program identified missed opportunities in diagnosis based on clinician reports, patient complaints, and risk management, and used trained facilitators to provide feedback to clinicians about these missed opportunities as learning opportunities. Both facilitators and recipients found the program to be useful and believed it would improve future diagnostic safety.
Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.
This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.
Hussain F, Cooper A, Carson-Stevens A, et al. BMC Emerg Med. 2019;19:77.
This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency departments in England and Wales. The majority of incidents (86%) were delayed diagnoses; the remainder were wrong diagnoses. The authors identified three themes stemming from human factors that contributed to the diagnostic errors: insufficient assessment (e.g., failure to order imaging or refer patients when indicated), inappropriate response to diagnostic imaging, and failure to order diagnostic imaging. Potential interventions to address these contributors are briefly discussed.
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. BMC Med Inform Decis Mak. 2019;19:174.
There are challenges to identifying and measuring diagnostic errors in healthcare settings. This systematic review found evidence that team meetings, error documentation, and trigger algorithms in various clinical settings may reduce diagnostic errors. The authors also found that while there have been numerous studies on interventions targeting diagnostic errors, few such interventions are being used in clinical settings.
Zachariasse JM, Kuiper JW, de Hoog M, et al. J Pediatr. 2016;177:232-237.e1.
Emergency department triage systems are designed to prioritize patients based on the level of illness. Inappropriate triage can lead to delays in care and adverse events. In Europe, the Manchester Triage System is a widely used algorithm that classifies patients based on five levels of urgency with a corresponding maximum waiting time. This study sought to assess the effectiveness of the Manchester Triage System in children requiring admission to the intensive care unit (ICU). Analyzing more than 50,000 consecutive emergency department visits of children younger than 16, the authors determined that almost one third of children admitted to the ICU were undertriaged. Risk factors identified for undertriage included age younger than 3 months, type of medical presenting problem, presence of underlying chronic conditions, referral by a specialist or emergency medical services, and arrival during the evening or at night. These findings suggest that the Manchester Triage System inappropriately triages a significant proportion of children requiring ICU admission and that modifications should be made to improve safety in pediatric emergency care. A previous WebM&M commentary discussed the challenges of triage in the emergency department.
Bashkin O, Caspi S, Swissa A, et al. J Patient Saf. 2020;16:47-51.
This pre-post study found that a human factors approach improved blood collection procedures in the emergency department, which is important for preventing adverse events such as transfusion errors. This demonstrates the benefits of applying human factors engineering in patient safety efforts across health care settings.
Wittich CM, Lopez-Jimenez F, Decker LK, et al. J Gen Intern Med. 2011;26:293-8.
Reflection, or thinking about thinking, is often used as a technique to encourage learning from adverse events. This study describes the development and pilot testing of a case-based system to encourage and measure reflection among faculty physicians at an academic medical center.
Gedeborg R, Thiblin I, Byberg L, et al. Crit Care Med. 2009;37.
The continuing decline in the performance of autopsies has led to considerable concern that physicians are increasingly unaware of diagnostic errors. Missed diagnoses may also adversely affect the accuracy of prognostic systems. This Swedish study compared hospital discharge data and autopsy data for trauma patients and found that missed injuries were relatively common despite an autopsy rate of less than 25%. The performance of the International Classification of Diseases Injury Severity Score—a commonly used prognostic tool for trauma patients—could have been improved by incorporating autopsy data. As in prior studies, the authors conclude that maintaining a high autopsy rate is essential to improving the accuracy of clinical diagnoses.
Griffey RT, Bohan JS. Qual Saf Health Care. 2006;15:344-6.
This study found that other health care providers were a relatively frequent source of complaints for the emergency department, and the issues they raised could be used to identify opportunities to improve quality and safety.
The author comments on the conditions that allow for confirmation bias in emergency medicine decision making and suggests automation, cognitive forcing strategies, and metacognition as strategies to minimize its occurrence.
Ursprung R. Qual Saf Health Care. 2005;14:284-289.
This pilot study evaluated the feasibility of using a safety auditing checklist during daily work in an intensive care unit. Investigators developed a 36-item list focused on errors common to this clinical setting and implemented them into rounds on a regular basis for the 5-week study period. Results suggested the ability to detect a variety of errors while engaging staff in a blame-free fashion to stimulate immediate changes in performance. The authors advocate for greater application of safety and error prevention methods into routine clinical work as a mechanism for ongoing quality improvement.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.