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 28 Results

Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.

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Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.

As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

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Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;10:417-423.

Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

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.

Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients.

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Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. J Am Heart Assoc. 2022;11:e025026.

Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.

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Diagnostic Safety

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.

Undiagnosed and rare diseases in critical care: the role of diagnostic access.

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Bordini BJ. Crit Care Clin. 2022;38:159-171.

Rare diseases can present diagnostic challenges to clinicians. This article discusses how cognitive biases can impede diagnosis of rare conditions and strategies to improve diagnostic safety in critical care, such as diagnostic timeouts.

Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.

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WebM&M Case July 8, 2022

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits.

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Maternal Safety

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.

Errors in adult trauma resuscitation: a systematic review.

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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.

Improving Diagnosis and Treatment of Maternal Sepsis.

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Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.

This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis patient.

Think Like a Surgeon

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WebM&M Case September 25, 2019

A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear.

Getting the Diagnosis Both Right and Wrong

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WebM&M Case September 25, 2019

A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures.

What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectives.

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Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.

The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.

Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.

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Bergl PA, Nanchal RS, Singh H. Ann Am Thorac Soc. 2018;15:903-907.

Elements of critical care can influence the reliability of diagnosis, teamwork, and care delivery. This commentary recommends areas for research to reduce diagnostic error in the intensive care unit. The authors highlight the need for intensivist involvement to define distinct roles and actions in their specialty for diagnostic improvement.

Cognitive Overload in the ICU

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WebM&M Case August 21, 2016

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.

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Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-91.

A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.

Duty to Disclose Someone Else's Error?

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WebM&M Case May 1, 2011

Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.

What Do We Know About Emergency Department Safety?

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Perspective on Safety June 1, 2010

Emergency medicine has evolved from a location, with variably trained and experienced providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus on the diagnosis and care of undifferentiated acute problems.(1) The importance of rapid diagnosis and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has made timeliness not simply a determinant of patient satisfaction but also a significant safety and quality concern—delays in care can be deadly.(2) Emergency physicians (EPs) have identified delays caused by crowding fr

In Conversation with…Pat Croskerry, MD, PhD

Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.

The nature and causes of unintended events reported at ten emergency departments.

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Smits M, Groenewegen PP, Timmermans D, et al. BMC Emerg Med. 2009;9:16.

Emergency department (ED) patients are particularly vulnerable to adverse events, and a prior study of closed malpractice claims implicated systems factors such as poor teamwork in adverse patient outcomes. This study used root cause analysis of incident reports to identify the types and causes of errors and unanticipated events in the ED. Incidents included poor communication and teamwork, particularly with other departments, but medication errors and diagnostic errors were also noted. The authors recommend that organizations integrate the ED into hospital-wide safety improvement efforts.

All in the History

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WebM&M Case March 21, 2009

Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.

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