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 72 Results

Diagnosing fast and slow: cognitive bias in obstetrics.

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Atallah F, Gomes C, Minkoff H. Obstet Gynecol. 2023;142:727-732.

Researchers describe two types of decision making in medicine - fast (intuitive) and slow (analytical). While both types are subject to bias, this paper describes how cognitive biases in fast thinking, such as anchoring or framing, as well as racial or moral bias, can result in obstetrical misdiagnosis. Ten steps to mitigate these cognitive biases are laid out.

Intraoperative communications between pathologists and surgeons: do we understand each other?

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Wiggett A, Fischer G. Arch Pathol Lab Med. 2023;147:933-939.

Miscommunication between pathologists and surgeons can lead to significant patient harm. This study identified multiple discrepancies between pathologist-listed diagnoses included in intraoperative consult notes compared to surgeon-dictated operative notes. Discrepancies were most common in multipart cases and those involving deferrals.

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2023.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

Advancing Diagnostic Excellence in Maternal Health Care.

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Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Irvine, CA: Arnold and Mabel Beckman Center: 2021-2023.

These free workshops discussed current challenges in diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities, cancer misdiagnoses and problems in the care of older adults that affect diagnosis.

Evidence for anchoring bias during physician decision-making.

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Ly DP, Shekelle PG, Song Z. JAMA Intern Med. 2023;183:818-823.

Anchoring bias is the tendency to focus on an initial diagnosis despite later evidence to the contrary. This study measured physicians’ potential anchoring bias regarding patients with congestive heart failure (CHF) with shortness of breath presenting to the emergency department. When the patient’s initial triage note included CHF, physicians were less likely and/or slower to test for pulmonary embolism (PE) than when the triage note did not mention CHF. This suggests physicians may have been subject to anchoring bias.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Cognitive bias and dissonance in surgical practice: a narrative review.

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Richburg CE, Dossett LA, Hughes TM. Surg Clin North Am. 2023;103:271-285.

Cognitive biases can threaten patient safety in a variety of ways. This narrative review summarizes the common cognitive biases in surgical care and how they threaten patient safety, including delays in diagnosis and treatment, unnecessary surgeries, and intraoperative errors and complications. The authors also discuss cognitive debiasing strategies to mitigate the impact of cognitive biases.

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias.

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Pisciotta W, Arina P, Hofmaenner D, et al. Anaesthesia. 2023;78:501-509.

A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

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Richmond JG, Burgess N. J Health Organ Manag. 2023;37:327-342.

Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

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Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

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Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

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.

Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department.

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Manojlovich M, Krein SL, Kronick SL, et al. Rockville, MD: Agency for Healthcare Research and Quality; August 2022. AHRQ Publication No. 22-0026-2-EF.

Nurses are increasingly discussed as diagnostic team members. The knowledge of the team as a unit, or distributed cognition, is considered as an asset to diagnosis that rests on relationships between nurses, physicians, and patients. This issue brief is part of a series on diagnostic safety.

Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.

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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.

The Uneven Burden of Maternal Mortality in the U.S.

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NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Pediatric musculoskeletal radiographs: anatomy and fractures prone to diagnostic error among emergency physicians.

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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.

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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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.

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