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 1708 Results

Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS).

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Ravindran S, Matharoo M, Rutter MD, et al. Endoscopy. 2023;Epub Sept 18.

Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

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WebM&M Case November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

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Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review.

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study.

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Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.

Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.

Detection rates of mild cognitive impairment in primary care for the United States Medicare population.

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Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.

Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

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Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

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Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.

Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.

Preferred language and diagnostic errors in the pediatric emergency department.

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Lowe JT, Leonard J, Dominguez F, et al. Diagnosis (Berl). 2023;Epub Oct 6.

Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.

Diagnostic Safety and Quality Webinar Series: Overview and Implications for Hospitals.

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The Leapfrog Group. November 28, 2023, 3:00--4:00 PM (eastern).

Diagnostic errors in hospitals are the focus on continued improvement efforts as they are common, costly, and harmful. This last in a three-part series of webinars will focus on existing learning strategies to improve diagnosis in hospitals. Dr. Divvy Upadhyay is the featured speaker.

Assessing biases in medical decisions via clinician and AI chatbot responses to patient vignettes.

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Kim J, Cai ZR, Chen ML, et al. JAMA Netw Open. 2023;6:e2338050.

Artificial intelligence (AI) is increasingly used in healthcare, but concerns have been raised that it can exacerbate existing disparities because of underlying biases in AI tools. In this observational study, researchers evaluated biases in clinician versus AI chatbox responses to 19 clinical vignettes involving cardiology, emergency medicine, rheumatology, and dermatology. Findings indicate that both AI chatboxes and clinicians provide different clinical recommendations based on a patient’s gender, race/ethnicity, and socioeconomic status under certain clinical scenarios.

Frequency, type, and degree of potential harm of adverse safety events among pediatric emergency medical services encounters.

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Cicero MX, Baird J, Brown L, et al. Prehosp Emerg Care. 2023;Epub Sep 12.

The pediatric population faces unique challenges in the prehospital setting. This prospective chart review study classified adverse safety events (ASE) of pediatric patients at 15 emergency medical services (EMS) agencies. More than 20% of encounters contained at least one ASE, although most were unlikely to cause harm (e.g., missed documentation).

The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.

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Ali KJ, Goeschel CA, DeLia DM, et al. Diagnosis (Berl). 2023;Epub Oct 5.

To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

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Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.

Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis.

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van Moll C, Egberts TCG, Wagner C, et al. J Patient Saf. 2023;19:573-579.

Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.

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.

Radiologist age and diagnostic errors.

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Lamoureux C, Hanna TN, Callaway E, et al. Emerg Radiol. 2023;30:577-587.

Clinician skills can decrease with age. This retrospective analysis of 1.9 million preliminary interpretations of radiology imaging findings examined the relationship between radiologist age and diagnostic errors. While the overall mean error rate for all radiologists was low (0.5%), increasing age was associated with increased relative risk of diagnostic errors.

Community validation of an approach to detect delayed diagnosis of appendicitis in big databases.

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Michelson KA, McGarghan FLE, Waltzman ML, et al. Hosp Pediatr. 2023;13:e170-e174.

Trigger tools are commonly used to detect adverse events and identify areas for safety improvement. This study found that trigger tools using electronic health record-based data can accurately identify delayed diagnosis of appendicitis in pediatric patients in community emergency department (ED) settings.

Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.

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Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.

As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.

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