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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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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.
Liberman AL, Cheng NT, Friedman BW, et al. Diagnosis (Berl). 2022;9:225-235.
Missed diagnosis of stroke in emergency medicine settings is an important patient safety problem. In this study, researchers interviewed emergency medicine physicians about their perspectives on diagnostic neurology and use of clinical decision support (CDS) tools. Themes emerged related to challenges in diagnosis, neurological complaints, and challenges in diagnostic decision-making in emergency medicine, more generally. Participating physicians were enthusiastic about the possibility of involving CDS tools to improve diagnosis for non-specific neurological complaints.
WebM&M Case August 25, 2021

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Ramnarayan P, Cronje N, Brown R, et al. Emerg Med J. 2007;24:619-24.
Diagnostic errors are common and often related to cognitive processes, with many retrospectively discovered through review of closed malpractice claims or at time of autopsy. This study used a web-based clinical decision support system called Isabel to determine its ability to accurately diagnose acute medical problems compared with final discharge diagnoses and a panel of experts. Building on a past study, investigators discovered that the system displayed the final discharge diagnosis in 95% of inpatients. The authors highlight the potential benefits of integrating such a system into daily practice and call for further study on whether it reduces diagnostic error. An AHRQ WebM&M conversation with Dr. Britto, the co-founder of Isabel Healthcare Inc., discusses eradicating diagnostic errors through such decision support systems.