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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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Displaying 1 - 16 of 16 Results
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.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;18:e1135-e1141.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Curated Libraries
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.
Fernholm R, Holzmann MJ, Wachtler C, et al. BMC Fam Pract. 2020;21.
Much of the evidence about preventable harm in patients with psychiatric illnesses is limited to inpatient psychiatric facilities. This case-control study explores patient-related factors that place patients at an increased risk for patient safety incidents in primary or emergency care. While differences in income, education, and foreign background had some association with preventable harm, researchers found that psychiatric illness nearly doubled the risk of preventable harm among both emergency and primary care patients, with nearly half (46%) of harm attributable to diagnostic errors.
Newman-Toker DE, Moy E, Valente E, et al. Diagnosis (Berl). 2014;1:155-166.
This observational study identified patients who visited the emergency department within 30 days prior to a stroke diagnosis. Nearly 13% of patients had a potential missed diagnosis, and more than 1% had a probable missed diagnosis of stroke. This study illustrates a novel approach to characterizing the incidence of missed diagnosis, an important and understudied patient safety problem.
Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.
Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.
Lin Y-K, Lin C-J, Chan H-M, et al. Injury. 2014;45:83-7.
Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.
Petinaux B, Bhat R, Boniface K, et al. Am J Emerg Med. 2011;29:18-25.
This study found that only 3% of radiographs were misinterpreted by emergency physicians on a subsequent interpretation by a radiology attending. The most commonly missed findings included fractures, dislocations, and pulmonary nodules. A past AHRQ WebM&M commentary discussed radiographic errors in the emergency department.
Diaz S, Ekberg O. Acta Radiol. 2010;51:934-8.
Relatively few studies have examined diagnostic errors in radiology. This study, conducted at a teaching hospital in Sweden, used a database of more than 19,000 radiologic studies to identify patient- and physician-specific risk factors for incorrect diagnoses. Interpretation errors occurred more frequently in children and very elderly patients (older than 85 years). Errors were also more likely when the initial interpretation was performed by a resident or by an on-call staff radiologist interpreting films outside of his or her normal specialty. An AHRQ WebM&M commentary discusses a case in which an errant initial interpretation of a CT scan led to initiation of a risky treatment plan.
Mamede S, van Gog T, van den Berge K, et al. JAMA. 2010;304:1198-1203.
Diagnostic errors are frequently ascribed to cognitive errors on the part of clinicians. Prominent among these is availability bias, when clinicians choose the most available diagnosis—the first that comes to mind—when faced with a complex diagnostic scenario. In this Dutch study, internal medicine residents were presented with a series of diagnosed cases, then given cases with similar symptoms and asked to record their provisional diagnoses. The investigators did find evidence of availability bias, but also found that asking residents to reflect on their diagnostic process mitigated the effects of availability bias. Diagnostic errors have been termed the next frontier in patient safety, and an AHRQ WebM&M commentary discusses reflective practice and other methods of avoiding cognitive error in diagnosis.
Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. 2007;49:196-205.
This study addressing the causes of missed and delayed diagnoses in emergency department patients used similar methodology as a companion study of error in the ambulatory setting and a prior study of surgical patients. Errors involved a broad range of patients and conditions. As in the outpatient arena, errors generally occurred due to failure to order diagnostic tests or interpret them correctly; factors contributing to error included cognitive factors (ie, physician judgment or knowledge), but system factors (ie, fatigue or communication breakdowns) were involved in a significant proportion of cases. As was also found in the study of ambulatory patients, the multifactorial nature of the errors identifies many potential areas for action but likely defies simple solutions.