Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.

Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.

Delayed cancer diagnosis is a critical patient safety concern in primary care. Rectal bleeding is an important issue to recognize promptly, because it may be a symptom of colon cancer, for which delayed diagnosis can lead to worse outcomes. For this retrospective study, physician reviewers examined 438 abstracted medical records of patients with rectal bleeding to identify problems in the diagnostic process. In the majority of cases, they identified problems such as failure to elicit sufficient family history, incomplete physical examination performance or documentation, and lack of needed laboratory testing. Consistent with prior studies, failure to order laboratory testing and plan follow-up were associated with worse care quality. These findings emphasize the challenges of achieving timely and accurate diagnosis in the outpatient setting. In a related editorial, Hardeep Singh suggests that enhancing electronic health record capability and trigger tools could address diagnostic delays in primary care.

Electronic prescribing systems have been shown to prevent medication errors in the outpatient setting. However, such systems do not routinely notify pharmacies if a clinician has decided to stop prescribing a medication, creating the potential for harm. Conducted in 15 primary care practices that use a commercial electronic medical record system, this study found that 1.5% of prescriptions discontinued by physicians were subsequently dispensed at least once by pharmacies. Since these medications included high-risk therapies such as antidiabetic and antiplatelet agents, some patients may have experienced preventable harm as a result. This study identifies a previously undocumented type of error in ambulatory care and describes the need to harness technology to facilitate bidirectional communication between providers.

Promoting physician engagement in work to improve the quality and safety of care is critically important, but an ongoing challenge. This qualitative study conducted site visits and semistructured interviews to describe thematic strategies for physician engagement at 10 high-performing hospitals. The authors developed a six-point framework to highlight best practices, which included engaged leadership, a physician compact, appropriate compensation, realignment of financial incentives, clinical data, and ties to promotion. The largest barriers to engagement were lack of time and institutional culture. A past Joint Commission Sentinel Event Alert focused on leadership as a key component to fostering a culture of safety and promoting provider engagement.

Less than 20% of ambulatory practices in the United States utilize electronic health records (EHRs). Uptake has been limited by cost issues and concern about the impact of EHRs on clinician workflow. This survey evaluated clinicians' perceptions of a newly implemented electronic medical record in three primary care clinics. Although initially clinicians felt that the EHR resulted in longer patient visits and increased the time spent documenting, by 1 year after implementation, clinicians felt that the EHR improved their ability to follow up on test results and communicate with other providers, and contributed to higher quality care overall. Importantly, these perceived advantages emerged only after 1 full year of using the new system.

Electronic reminders to clinicians are one of the earliest methods used to improve patient safety. In this cluster-randomized controlled trial conducted in primary care clinics, clinicians received targeted reminders within the existing electronic medical record prompting them to order laboratory tests to detect adverse medication effects. The most encouraging study result was that clinicians were generally already monitoring patients as recommended—in contrast to data from prior studies—and as a result, the reminders did not appreciably increase test ordering. Prior research has addressed barriers to effective implementation of electronic reminders.

Nearly 1 in 10 patients hospitalized for an acute myocardial infarction (AMI) in this cohort study had seen an outpatient physician within 30 days before the event but were not immediately referred for appropriate diagnostic testing, despite having symptoms concerning for AMI. Failure to use appropriate risk stratification methods such as the Framingham score may have accounted for these missed diagnoses.

This survey identified problems with the way test results are handled in ambulatory settings. Investigators asked physicians about their practice patterns in managing test results, their satisfaction with current systems, and what features could address existing deficiencies. Results revealed significant delays in reviewing test results, poor satisfaction with current management strategies, and the need for a tool that both helps generate patient letters and improves workflow. The authors conclude that current levels of dissatisfaction with management of test results indicate a need for systems or tools to improve the process.