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 948 Results

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Mark Graber Diagnostic Quality & Safety Award.

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Society to Improve Diagnosis in Medicine.

Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The deadline to submit a 2023 nomination is September 12, 2023.

Inside the preventable deaths that happened within a prominent transplant center.

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Blau M. ProPublica. June 14, 2023.

Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.

Introducing second-year medical students to diagnostic reasoning concepts and skills via a virtual curriculum.

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Chang C, Varghese N, Machiorlatti M. Diagnosis (Berl). 2023;10:105-109.

Clerkship directors indicate clinical and diagnostic reasoning education should be included in medical school curricula, but up to half of programs do not offer it. This article describes the development, implementation, and evaluation of a diagnostic reasoning virtual training for pre-clinical medical students. Students reported increased confidence and understanding of diagnostic reasoning.

How do we learn about error? A cross-sectional study of urology trainees.

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Browne C, Crone L, O'Connor E. J Surg Educ. 2023;80:864-872.

While medical trainees and residents agree that disclosing errors to patients is important, they also perceive barriers to doing so. In this study, surgical trainees described factors influencing their decisions not to disclose errors despite their intention to do so. Even with formal communication trainings throughout the program, participants reported a lack of sufficient education in error disclosure. Workplace culture and role-modelling influenced their own disclosure practices both positively and negatively.

Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training.

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Kennedy GAL, Pedram S, Sanzone S. Safety Sci. 2023;165:106200.

Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.

Cognitive biases in internal medicine: a scoping review.

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Loncharich MF, Robbins RC, Durning SJ, et al. Diagnosis (Berl). 2023;10:205-214.

Cognitive biases, such as heuristics, help clinicians make rapid decisions, but these biases can result in errors. This review sought to explore biases in internal medicine, the impact of biases on patient outcomes, and the effect of debiasing strategies. Forty-one biases were studied, and debiasing strategies showed little to no effect on reducing bias.

The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors.

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D’Angelo A-LD, Kapur N, Kelley SR, et al. Surgery. 2023;174:222-228.

Prior research has asked surgeons how they cope with intraoperative errors, but this study asks operating room personnel how they perceive surgeons' coping strategies. Positive response strategies included announcing that an error has occurred and the plan for managing it. Negative responses include the surgeon becoming visibly upset, raising their voice, and blaming others. The authors suggest additional education on positive strategies to cope with errors during medical education and residency.

Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections.

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Carter RG, Lake S. Pediatrics. 2023;151.

This commentary co-written by a medical student and a faculty member explores the presence and impact of implicit bias on the clinician team and patients. The piece introduces a four-step framework through which to examine the origins of bias, how its described, its care impact and how to reduce its effect.

A scoping review of distributed cognition in acute care clinical decision-making.

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Wilson E, Daniel M, Rao A, et al. Diagnosis (Berl). 2023;10:68-88.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms.

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Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.

Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals.

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Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.

Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2023.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2022 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional sections cover educational, publication, and learning management system efforts.

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.

Racism and electronic health records (EHRs): perspectives for research and practice.

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Emani S, Rodriguez JA, Bates DW. J Am Med Inform Assoc. 2023;30:995-999.

Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.

Technology as a Tool for Improving Patient Safety

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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.

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