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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 83 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.
Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.
Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.

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.
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.
Lamoureux C, Hanna TN, Sprecher D, et al. Emerg Radiol. 2021;28:1135-1141.
Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.
Singh H, Connor DM, Dhaliwal G. BMJ. 2022;376:e068044.
System and clinician behaviors affect the reliability of the diagnostic process. This article shares five strategies to enhance individual clinician diagnostic practices which include seeking feedback, building learning into daily work, considering bias, enabling critical thinking, and teaming.
Patient Safety Innovation January 26, 2022

The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.

Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.
The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.
Patient Safety Innovation September 29, 2021

The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO). In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care. CHOC researchers used these "Great Catches" to identify potential diagnostic errors.

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, care standardization,teamwork, unit-based safety initiatives, and...
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;28:2202-2211.
Based on the Safer Dx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.
DeGrave AJ, Janizek JD, Lee S-I. Nat Mach Intell. 2021;3:610–619.
Artificial intelligence (AI) systems can support diagnostic decision-making. This study evaluates diagnostic “shortcuts” learned by AI systems in detecting COVID-19 in chest radiographs. Results reveal a need for better training data, improved choice in the prediction task, and external validation of the AI system prior to dissemination and implementations in different hospitals.  

Mangus CW, Singh H, Mahajan P. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 20(21)-0040-4-EF.

Health information technology (Health IT) presents opportunities to engage patients and families in decision making. This issue brief highlights health IT tools that can close this communication gap to engage patients in diagnosis in the emergency room. This brief is part of a publication series examining diagnostic improvement across health care.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Wright B, Lennox A, Graber ML, et al. BMC Health Serv Res. 2020;20:897.
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm. The authors synthesized systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures. The review identified several avenues for improving closed-loop communication through the use of technology, audit and feedback, and use of point-of-care or bedside testing.
Auerbach AD, O'Leary KJ, Greysen SR, et al. J Hosp Med. 2020;15:483-488.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).
Covin Y, Longo P, Wick N, et al. Diagnosis (Berl). 2020;8:161-166.
As one strategy to improve diagnosis, this article describes the use of computerized case presentations and facilitated discussions (based on the National Academy of Medicine diagnostic process framework) for teaching diagnostic reasoning education to clerkship and preclinical medical students.  
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.