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.
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.
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.
Scott IA, Campbell DA. Med J Aust. 2018;208:196-197.
Leaders in the effort to improve diagnosis have heralded diagnosis as a team activity. This commentary suggests that specialists are more vulnerable to anchoring bias and more siloed approaches to problem solving than their generalist colleagues when faced with complex diagnostic problems. The authors recommend that specialists hone their generalist skills, seek multidisciplinary consultation, and focus on patient-centered rather than disease-centered care to ensure a wide range of considerations are explored to avoid diagnostic error.
Graber ML, Rusz D, Jones ML, et al. Diagnosis (Berl). 2017;4:225-238.
Teamwork has been highlighted as a key component of patient safety that also applies to improving diagnosis. This commentary describes how the team approach to diagnosis is anchored in patient-centered care and suggests that the diagnostic team must expand beyond the focus on physicians and involve a wide range of professionals, including pathologists, allied health practitioners, and medical librarians.
Taylor JR, Thompson PJ, Genzen JR, et al. Lab Med. 2017;48:97-103.
Diagnostic error represents a significant source of patient harm. In this study, researchers surveyed physicians to understand how to improve the involvement of laboratory professionals in assisting with diagnostic challenges. They conclude that there may be a greater role for laboratory professionals in the diagnostic process beyond providing test results.
Hautz WE, Kämmer JE, Schauber SK, et al. JAMA. 2015;313:303-4.
This simulation study found that diagnostic performance by fourth-year medical students improved when they worked in pairs compared to when they worked individually. The authors suggest that working collaboratively allowed students to avoid cognitive biases that can impede timely and correct diagnosis. These results emphasize the importance of real-time feedback in the diagnostic process.
Groszkruger D. J Healthc Risk Manag. 2014;34:38-43.
Highlighting how uncertainty around identifying diagnostic errors hinders measuring its incidence and developing solutions, this commentary outlines methods to augment diagnostic safety including teamwork activities, establishing best practices, and utilizing decision support systems.
Smits M, Groenewegen PP, Timmermans DRM, 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.
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