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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 - 20 of 226 Results

Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.
Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.1 Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.
Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.
Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;45:242-253.
Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   
Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19:211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims with at least one diagnostic error were analyzed. No singular factor was identified; instead multiple contributing factors were implicated along the diagnostic pathway.
Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Curated Libraries
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.
Danielson KK, Rydzon B, Nicosia M, et al. JAMA Netw Open. 2023;6:e2253275.
Patients with diabetes may not be aware of their condition and therefore may not seek timely care. In this pilot study, patients presenting to the emergency department at risk of type 2 diabetes were flagged by the electronic health record. Clinicians could then add hemoglobin A1c (HbA1c) to scheduled blood draws. Of the patients with elevated HbA1c levels contacted by study staff, three-quarters were not aware of a previous diabetes diagnosis.
Hailu EM, Maddali SR, Snowden JM, et al. Health Place. 2022;78:102923.
Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
Boxley C, Krevat SA, Sengupta S, et al. J Patient Saf. 2022;18:e1196-e1202.
COVID-19 changed the way care is delivered to hospitalized patients and resulted in new categories and themes in patient safety reporting. This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors, pressure ulcers, and falls.
Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.
Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.
Kanter MH, Ghobadi A, Lurvey LD, et al. Diagnosis (Berl). 2022;9:430-436.
Diagnostic errors are an emerging area of patient safety research; as such, innovative methods to identify and prevent diagnostic errors are being developed. This commentary describes the development, implementation, and sustainment of a novel method of investigation. The e-Autopsy/e-Biopsy method includes dedicated patient safety staff and volunteer clinical specialists to review events and identify trends. The process is illustrated with three diagnoses: ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer.
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.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2023;10:4-8.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.
Plint AC, Newton AS, Stang A, et al. BMJ Qual Saf. 2022;31:806-817.
While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.
Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;48:492-496.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
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.

Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.

Improving diagnosis and reducing diagnostic errors are patient safety priorities. This announcement supports the development of Diagnostic Centers of Excellence focused on improving frontline diagnostician support and improving diagnostic systems (i.e., improving diagnostic precision through consensus, improving “truth” or diagnostic reference standards). The application process is now closed.