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 55 Results

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.

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.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Notes on healing after a missed diagnosis.

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Fleming EA. JAMA. 2022;328:1297-1298.

Honest apology is known to support healing from medical error for clinicians, patients, and families. This essay shares the experience of one physician who missed signs of a heart attack, mislabeling the condition as fatigue, who then apologized for the mistake. The author highlights how openness about the error was crucial in the continuation of the care relationship.

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Diagnostic Safety

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.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

A family and hospital's journey and commitment to improving diagnostic safety.

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Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.

The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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WebM&M Case July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

‘You’re going to release him when he was hurting himself?’

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Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

What constitutes effective team communication after an error?

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Hart WM, Doerr P, Qian Y, et al. AMA J Ethics. 2020;22:E298-E304.

Communication has become a foci of improvement efforts across the spectrum of patient safety. This article discusses a surgical complication incident that illustrates the importance of transparency, disclosure and collaboration as elements of a successful approach to communication that can successfully manage the impact of an adverse incident.

Public sector organizational failure: a study of collective denial in the UK national health service.

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Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.

Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.

Report of the Independent Inquiry into the Issues Raised by Paterson.

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James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284.

Sharing information from large-scale failure investigations provides insights on latent factors that contribute to patient harm. This analysis discusses a criminal case involving one surgeon in the National Health Service. The examination uncovered problems perpetuated by culture, lack of respect for patient concerns, poor complaint follow-up and organizational blindness. The report summarizes recommendations to reduce similar situations through improving patient communication, organizational accountability and complaints management.

Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study.

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Nowotny BM, Davies-Tuck M, Scott B, et al. BMJ Qual Saf. 2021;30:186-194.

After a cluster of perinatal deaths was identified in 2015, the authors assessed 15-years of routinely collected observational data from 7 different sources (administrative, patient complaint and legal data) preceding the cluster to determine whether the incidents could have been predicted and prevented. The extent of clinical activity along with direct-to-service patient complaints were found to be the more promising for purposes of potential predictive signals. The authors suggest that use of some routinely collected data of these types show promise; however, further work needs to be done on specificity and sensitivity of the data and to gain access to comparator data is needed.

Error disclosure and apology in radiology: the case for further dialogue.

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Brown SD, Bruno MA, Shyu JY, et al. Radiology. 2019;293:30-35.

This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.

Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population.

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Byju AS, Mayo K. J Med Ethics. 2019;45:821-823.

Managing errors that affect patients who lack decision-making capacity and a designated decision-maker is a new area of concern. This commentary discusses moral, ethical, legal, and clinical reasons for health care to examine how to respond when such a situation occurs. The authors hope to motivate development of needed protocols and best practices to ensure that this vulnerable patient population is respectfully and completely informed after medical errors.

Hospital image repair strategies, organizational apology, and medical errors: an analysis of the CoxHealth brain over-radiation case.

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Carmack HJ. Health Comm. 2020;35:1466-1474.

Large-scale system failures can damage an organization's credibility. This commentary analyzes how one organization responded after an incident that involved 76 patients who mistakenly received fatally high doses of radiation. The strategies discussed center on the importance of organizational communication to patients, navigating the blame response, and rapid efforts to prevent similar events.

Patient preferences in cases of Inter-system Medical Error Discovery (IMED).

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Antunez AG, Saari A, Miller J, et al. Ann Surg. 2021;273:516-522.

Clinicians sometimes need to address errors committed by other providers, who may or may not be part of their own organization. This study used simulated cases to explore patient preferences for error disclosure when the disclosing provider was not involved in the error. Patients strongly preferred that these errors be treated similarly to other errors, asking for full disclosure whenever possible. A review article and a WebM&M commentary discuss frameworks for providers to use when disclosing errors committed by another clinician.

How Veterans Affairs failed to stop a pathologist who misdiagnosed 3,000 cases.

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Rein L. Washington Post. August 30, 2019.

Clinicians are often reluctant to report impaired or incompetent colleagues. This newspaper article discusses how a Veterans Affairs system pathologist with substance addiction continued to misdiagnose patients despite performance concerns raised by colleagues.

Reducing Diagnostic Error: Measurement Considerations.

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National Quality Forum

This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.

When there's no one to whom an error can be disclosed, how should an error be handled?

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Chiu RG. AMA J Ethics. 2019;21:E553-558.

Although disclosure of medical error to patients is difficult, it is an ethical responsibility. This article discusses situations involving patients who are incapacitated and unrepresented but have no surrogate present to assist in communication and care coordination. Despite this challenge, the author argues that the clinician and organization still have the responsibility to document what happened, communicate what is known, and rectify the mistake.

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