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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
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.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;18:e1135-e1141.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Lam D, Dominguez F, Leonard J, et al. BMJ Qual Saf. 2022;31:735-743.
Trigger tools and incident reporting systems are two commonly used methods for detecting adverse events.  This retrospective study compared the performance of an electronic trigger tool plus manual screening versus existing incident reporting systems for identifying probable diagnostic errors among children with unplanned admissions following a prior emergency department (ED) visit. Of the diagnostic errors identified by the trigger tool and substantiated by manual review, less than 10% were identified through existing incident reporting systems.
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.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;114:563-574.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.
Nikouline A, Quirion A, Jung JJ, et al. CJEM. 2021;23:537–546.
Trauma resuscitation is a complex, specialized care process with a high risk for errors. This systematic review identified 39 unique errors occurring in trauma resuscitation involving emergency medical services (EMS) handover; airway management; inadequate assessment and/or management of injuries; inadequate monitoring, transfusion/blood-related errors; team communication errors; procedure-related errors; or errors in disposition.

Cifra CL, Westlund E, Ten Eyck P, et al. Diagnosis (Berl). 2021;8(2):193-198. doi: 10.1515/dx-2020-0023.

Missed sepsis diagnosis can lead to increased morbidity, mortality and length of stay. Using administrative data, this retrospective study estimated the risk of potentially missed pediatric sepsis in several emergency departments. Approximately 8% of pediatric patients admitted to the hospital with sepsis experienced a treat-and-release emergency department visit within the prior 7 days. Administrative data can be helpful for hospitals in identifying cases that require detailed record review as well as evaluating the impact of sepsis alerts and bundles.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Bhat PN, Costello JM, Aiyagari R, et al. Cardiol Young. 2018;28:675-682.
Researchers surveyed pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United States. More than 80% of respondents perceived diagnostic errors to be common and 65% reported errors causing permanent harm to patients. Improving feedback and teamwork were frequently suggested as strategies for reducing diagnostic error.
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Pediatr Emerg Care. 2015;33:548-552.
Estimating weights in time-sensitive situations can lead to misdosing of weight-based medications. This prospective study of seven common weight-estimation techniques found that none were uniformly accurate. Calculation errors were common, especially in end-of-shift participants.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ. 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Davalos MC, Samuels K, Meyer AND, et al. Pediatr Crit Care Med. 2017;18:265-271.
Despite increased focus on improving diagnosis as a major patient safety issue, measuring and defining diagnostic error remains challenging. A prior study showed that application of the Safer Dx Instrument—a structured tool to help identify diagnostic errors in the primary care setting—enabled improved detection of diagnostic errors compared to chart review alone. In this study, researchers tested the ability of the instrument to identify diagnostic errors in high-risk patients admitted to the pediatric intensive care unit. Out of 214 high-risk patient charts, 26 were found to contain a diagnostic error. Two clinicians independently reviewed the records using the tool and reviewer agreement was 93.6%, suggesting that the Safer Dx Instrument may be useful in additional clinical settings. An Annual Perspective discussed the challenges associated with diagnostic error.
Vioque SM, Kim PK, McMaster J, et al. Am J Surg. 2014;208:187-194.
Approximately 1 in 13 deaths of patients with major trauma were considered preventable or potentially preventable in this retrospective review from an urban trauma center. Diagnostic errors during the initial trauma assessment were a frequent contributor to preventable harm.
Newman-Toker DE, Moy E, Valente E, et al. Diagnosis (Berl). 2014;1:155-166.
This observational study identified patients who visited the emergency department within 30 days prior to a stroke diagnosis. Nearly 13% of patients had a potential missed diagnosis, and more than 1% had a probable missed diagnosis of stroke. This study illustrates a novel approach to characterizing the incidence of missed diagnosis, an important and understudied patient safety problem.
Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.
Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.
Lin Y-K, Lin C-J, Chan H-M, et al. Injury. 2014;45:83-7.
Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.
Winters B, Custer J, Galvagno SM, et al. BMJ Qual Saf. 2012;21:894-902.
In the quest to improve patient safety, diagnostic errors have been underemphasized and as a result have been termed the "next frontier" for the safety field. This systematic review of autopsy studies sought to estimate the incidence of diagnostic errors contributing to death (class I errors) in intensive care unit (ICU) patients, compared with a prior systematic review that identified a 4.1% class I error rate across all patients undergoing autopsy. This review, which included 31 separate studies, found an overall class I error rate of 8% in ICU patients, with vascular events and infections accounting for most missed diagnoses. Despite the continuing utility of autopsies in improving diagnostic performance, autopsy rates in the United States have been steadily declining, leading to calls for efforts to increase autopsy rates.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.