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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 73 Results
Reyes AM, Royan R, Feinglass J, et al. JAMA Surg. 2023;Epub Jan 18.
Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.
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.
Michelson KA, McGarghan FLE, Patterson EE, et al. BMJ Qual Saf. 2022;Epub Sep 30.
Adverse events in pediatric emergency departments (ED) are rare, but largely preventable. This study examined characteristics and risk factors of patients with delayed diagnosis (i.e., presented to the ED within one week of a previous visit) and patients without delayed diagnosis of one of 7 serious medical conditions. Patients who were Hispanic or non-Hispanic Black, had public or other insurance, or non-English speaking were associated with delayed diagnosis.
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.
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.
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
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.
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.
Dregmans E, Kaal AG, Meziyerh S, et al. JAMA Netw Open. 2022;5:e2218172.
Inappropriate antibiotic prescribing can result in patient harm and costly antibiotic-resistant infections. Health record review of 1,477 patients admitted from the emergency department for suspected bacteremia infection revealed that 11.6% were misdiagnosed at infection site, and 3.1% did not have any infection. Misdiagnosis was not associated with worse short-term clinical outcomes but was associated with potentially inappropriate broad-spectrum antibiotic use.
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.
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.
Lam D, Dominguez F, Leonard J, et al. BMJ Qual Saf. 2022;31:735-743.
Trigger tools and incident reporting systems are two commonly used methods for detecting adverse events.  This retrospective study compared the performance of an electronic trigger tool plus manual screening versus existing incident reporting systems for identifying probable diagnostic errors among children with unplanned admissions following a prior emergency department (ED) visit. Of the diagnostic errors identified by the trigger tool and substantiated by manual review, less than 10% were identified through existing incident reporting systems.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Bastakoti M, Muhailan M, Nassar A, et al. Diagnosis. 2022;9:107-114.
Misdiagnosis in the emergency department (ED) can result in increased morbidity and mortality. This retrospective chart review of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge diagnoses. Results show 21.77% of patients had discordant diagnoses; discordant diagnosis was associated with increased length of stay, mortality, and up-triage to ICU.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
Building on prior research on missed myocardial infarction, this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations.
Kukielka E. Patient Saf. 2021;3:18-27.
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.
Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4:e2122248.
Diagnostic errors, including delayed diagnoses, continue to be a patient safety concern. This case-control study of children treated at five pediatric emergency departments explored the preventability of delayed diagnosis of pediatric appendicitis and associated outcomes. Researchers estimated that 23% of delayed diagnosis cases were likely to be preventable and that delayed diagnosis led to longer hospital length of stay, higher perforation rates, and additional surgical procedures.
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.