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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73537/psn-pdf
    July 28, 2021 - discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50576/psn-pdf
    October 23, 2019 - encounter (e.g., history and physical examination, symptom assessment, and ordering of diagnostic tests
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60231/psn-pdf
    April 15, 2020 - original diagnosis and one-third resulted in preventable harm to patients (e.g., regular blood glucose tests
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73435/psn-pdf
    June 30, 2021 - of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37941/psn-pdf
    July 30, 2008 - finding-blunders-thyroid-testing-experience-newborns Inconsistent and possibly erroneous results of thyroid tests
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35020/psn-pdf
    June 22, 2009 - surgical-skill-predicted-ability-detect-errors The investigators observed surgeons participating in three skills tests
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44573/psn-pdf
    October 21, 2015 - spend more time on the cognitive component of forming a diagnosis rather than simply ordering imaging tests
  8. psnet.ahrq.gov/issue/hidden-dangers-outsourcing-radiology
    December 19, 2007 - This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed
  9. psnet.ahrq.gov/web-mm/rapid-mis-strep
    February 01, 2004 - specificity (i.e., the ability of a positive test to detect the presence of group A streptococci) of these tests … Since essentially all rapid streptococcal tests are based upon an antigen-antibody reaction involving … While frequently used, it must be remembered that the specificity of rapid antigen detection tests is … Inadequate sampling of the posterior oropharynx can lead to false-negative results on rapid strep tests
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859342/psn-pdf
    December 20, 2023 - The patient with depression was rated as less likeable, and physicians ordered fewer diagnostic tests
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49530/psn-pdf
    February 01, 2007 - specificity (i.e., the ability of a positive test to detect the presence of group A streptococci) of these tests … Since essentially all rapid streptococcal tests are based upon an antigen-antibody reaction involving … While frequently used, it must be remembered that the specificity of rapid antigen detection tests is … Inadequate sampling of the posterior oropharynx can lead to false-negative results on rapid strep tests
  12. psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
    November 01, 2012 - It took a while for tests to come back and very often you could tell volumes with a good physical exam … But the reality is that we simply cannot be ordering tests willy-nilly the way we do right now. … We're going to have to ration some of the tests we order and justify them. … If you really sat and examined how many of these tests and angiograms and CT scans were really needed … It involves listening more carefully, examining more carefully, and choosing tests more judiciously.
  13. psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
    November 01, 2012 - Prompt, accurate diagnosis reduces the number of procedures and invasive tests, decreases the number … It took a while for tests to come back and very often you could tell volumes with a good physical exam … But the reality is that we simply cannot be ordering tests willy-nilly the way we do right now. … We're going to have to ration some of the tests we order and justify them. … If you really sat and examined how many of these tests and angiograms and CT scans were really needed
  14. psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
    August 15, 2018 - defined as chronic hypertension with new onset of proteinuria or onset of symptoms or abnormal blood tests … maternal BPs despite the use of antihypertensive medication, failure to obtain the appropriate laboratory tests … But, whatever the results of laboratory tests, a woman who is further than 37 weeks' gestation with twins … These included orders for type and frequency of blood tests, fetal monitoring, and surveillance of symptoms … for measurements of weight, blood pressure, urine, and documentation of required symptoms and blood tests
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - detrimental to patients, often because of overtreatment.(2-4) The above construct is true for many tests … An estimated 11% of inpatient microbiology tests result after discharge and approximately 2% of those … require follow-up or a change in therapy.(15) Since one-third of providers are unaware that tests pending … Discharging a patient with pending microbiology tests may be appropriate in certain situations, but … Tests can be falsely positive leading to over diagnosis and overtreatment.
  16. psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
    February 26, 2025 - You just repeat the tests. … What are the right screening tests and sequence of follow-up tests if these are positive to work up a … Based on new screening recommendations for high-risk patients, we're ordering many imaging tests to screen … These are situations where we should be doing few tests and referrals. … diagnosis in a much richer, more patient-centered way that is not just about ordering more or fewer tests
  17. psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
    July 21, 2025 - patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests … Prompt completion of diagnostic tests or referrals is paramount to receiving a... … patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests … Prompt completion of diagnostic tests or referrals is paramount to receiving a timely diagnosis and treatment … In this study, completion rates for three common diagnostic tests or referrals (i.e., colonoscopy, concerning
  18. psnet.ahrq.gov/issue/efficiency-and-thoroughness-trade-offs-high-volume-organisational-routines-ethnographic-study
    June 14, 2017 - September 1, 2016 Cognitive tests predict real-world errors: the relationship between … drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates
  19. psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
    August 04, 2015 - patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests … January 10, 2024 Completion of recommended tests and referrals in telehealth vs in-person
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50815/psn-pdf
    January 22, 2020 - record (EHR) systems has led to unanticipated patient safety concerns, such as duplicate orders for tests

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