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.
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.
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.
Li W, Stimec J, Camp M, et al. J Emerg Med. 2022;62:524-533.
While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.
Staal J, Speelman M, Brand R, et al. BMC Med Educ. 2022;22:256.
Diagnostic safety is an essential component of medical training. In this study, medical interns reviewed six clinical cases in which the referral letters from the general practitioner suggested a correct diagnosis, an incorrect diagnosis, or lacked a diagnostic suggestion. Researchers found that diagnostic suggestions in the referral letter did not influence subsequent diagnostic accuracy but did reduce the number of diagnoses considered.
Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.
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.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
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.
Isbell LM, Boudreaux ED, Chimowitz H, et al. BMJ Qual Saf. 2020;29:815–825.
Research has suggested that health care providers’ emotions may impact patient safety. These authors conducted 86 semi-structured interviews with emergency department (ED) nurses and physicians to better understand their emotional triggers, beliefs about emotional influences on patient safety, and emotional management strategies. Patients often triggered both positive and negative emotions; hospital- or systems-level factors primarily triggered negative emotions. Providers were aware that negative emotions can adversely impact clinical decision-making and place patients at risk; future research should explore whether emotional regulation strategies can mitigate these safety risks.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).
Dubosh NM, Edlow JA, Goto T, et al. Ann Emerg Med. 2019;74:549-561.
Misdiagnosis of a neurologic emergency such as stroke can lead to serious morbidity or mortality. Using a large multi-state database, this study examined the likelihood of readmission or inpatient mortality among patients who were initially discharged with nonspecific diagnoses of headache or back pain and found that 0.5% of headache and 0.2% of back pain patients experienced an inpatient death or serious neurological event after ED discharge. Extrapolated to a national level, this translates to over 55,000 patients with adverse outcomes due to a missed diagnosis for headache or back pain.
Shafer G, Singh H, Suresh G. Semin Perinatol. 2019;43:151175.
This article reviews diagnostic errors occurring in neonatal intensive care units (NICUs), error causes and contributing factors, and prevention strategies. NICU diagnostic errors are relatively understudied but may have long-term consequences for health and development of infants.
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.
Fitzsimons BT, Fitzsimons LL, Sun LR. Pediatrics. 2019;143:e20183458.
Rare diseases pose diagnostic challenges for physicians. This commentary offers insights from parents of a young child who died due to a delayed stroke diagnosis as well as from the patient's neurologist to raise awareness of childhood stroke and discuss the importance of partnership to heal from loss and advocate for improvement.
Roland D, Snelson E. Arch Dis Child Educ Pract Ed. 2019;104:43-48.
Clinical reasoning is a complex process that can be influenced by numerous factors. This review describes factors that influence decision-making in acute pediatric care. The authors discuss difficulty in history taking, biases, and other elements that can degrade the patient assessment required to inform appropriate diagnosis and treatment.
Lawton R, Robinson O, Harrison R, et al. BMJ Qual Saf. 2019;28:382-388.
Risk aversion in clinical practice may lead to the ordering of unnecessary tests and procedures, a form of overuse that may pose harm to patients. Experienced clinicians may be more comfortable with uncertainty and risk than less experienced providers. In this cross-sectional study, researchers surveyed doctors working in three emergency departments to understand their level of experience and used vignettes to characterize their reactions to uncertainty and risk. They found a significant association between more clinical experience and less risk aversion as well as a significant association between more experience and greater ease with uncertainty. The authors caution that they cannot draw conclusions on how these findings impact patient safety. An accompanying editorial suggests that feedback is an important mechanism for improving confidence in clinical decision-making. A WebM&M commentary discussed risks related to overdiagnosis and medical overuse.
Medical education has evolved to teach learners about improving patient safety. This commentary explores how relationships between patients, families, and physicians could help reduce diagnostic error and discusses the importance of providing education about clinical decision-making.
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