Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or referrals within the recommended timeframe can increase the risk of delayed diagnoses and patient harm.

Improving diagnostic quality is a patient safety priority. In this study, researchers used audio-recorded encounters, clinical note review, and interviews in order to evaluate a tool assessing key elements of diagnostic quality during clinical encounters. Many elements were reliably included in the clinical note or encounter transcript (e.g., follow-up contingencies, red flags) but other elements were often missing (e.g., psychosocial/contextual information). The researchers found that burnout was more common among physicians recording fewer key diagnostic elements.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

Delayed referrals from primary care providers to specialty care can lead to delayed diagnoses and patient harm. This retrospective analysis examined differences in timely versus delayed referrals for urgent skin cancer evaluations at one institution. Among 320 referrals occurring in 2018, 38% of evaluations occurred 31 days or more after the referral and nearly 11% of referrals were never completed. Delayed referrals were more common among patients who did not speak English and racial/ethnic minorities.

… uses and testing of the framework are described. … Linzer M, Sullivan EE, Olson APJ, et al. Improving diagnosis: adding context to …

In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.

Improving diagnosis is a patient safety priority. Using data from patient safety incident reports, malpractice claims, morbidity and mortality reports, and focus group responses, this study sought to identify “diagnostic pitfalls,” defined as clinical situations vulnerable to errors which may lead to diagnostic errors. The authors identified 21 generic diagnostic pitfall categories involving six different aspects of the clinical interaction – diagnosis and assessment, history and physical, testing, communication, follow-up, and other pitfalls (e.g., problems with inappropriate referral, urgency of the clinical situation not appreciated). The authors suggest that these findings can inform education and quality improvement efforts to anticipate and prevent future errors.

Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.

… and value alignment between clinicians and leaders . … Linzer M, Neprash H, Brown R, et al. Where trust flourishes: …

… Am J Med … Telemedicine has become a more accepted care mode due … telediagnosis in primary care. … Willis JS, Tyler C, Jr., Schiff GD, et al. Ensuring primary care diagnostic quality in the era of telemedicine. Am J Med. 2021;134(9):1101-1103. …

… J Gen Intern Care … Challenges to identifying and measuring … testing specific measures of diagnostic process safety. … Olson APJ, Linzer M, Schiff GD. J Gen Intern Med. Epub 2021 Feb 11. …

Burnout may adversely affect physician wellness and consequently patient safety. This cross-sectional study of 1,354 physicians found that depression was associated with suicidal ideation, while burnout was associated with self-reported medical errors.  

Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.  

This survey of 282 primary care physicians and ambulatory specialists found that several electronic health record design features contributed to clinician burnout, including excessive data entry requirements and long copied-and-pasted notes. However, other work environment factors (such as clinician workload) were more strongly predictive of work stress and burnout.

Medication errors occur frequently in the outpatient setting and can lead to patient harm. A common scenario is one in which a patient is prescribed multiple medications, does not know what each one is for, and takes them incorrectly. Medication safety experts have advocated that prescribers include indications on prescription labels to enable patients and pharmacists to check the bottle in order to remember a medication's purpose. Investigators examined more than 4 million outpatient prescriptions from a single institution and found that only 7.4% of prescriptions included an indication. Medications for symptoms like pain, nausea, and anxiety were much more likely to have indications than medications for chronic diseases. Internal medicine physicians, whose patients are more likely to take multiple medications, wrote indications 6% of the time. A PSNet perspective explored how community pharmacists can use medication indications and other tools to ameliorate medication-related harm.

Clinician burnout is a pressing patient safety issue. This pre–post study found that improving clinicians' work conditions (e.g., chaos, communication, values alignment, and cohesion) led to a subsequent reduction in burnout and increased likelihood of remaining in their medical practices. The findings suggest that clinicians' satisfaction can be improved by addressing workplace conditions.

Evidence suggests that computerized provider order entry (CPOE) systems improve medication safety by mitigating prescribing errors. However, CPOE systems may contribute to errors when user-centered design is not taken into account. In this study, researchers standardized the assessment of 10 distinct inpatient and ambulatory CPOE systems across 6 health care institutions to determine how variation in drug name display may increase the risk of medication errors. Using test patient scenarios, they found significant variation in drug name display, including inconsistencies with regard to the display of brand and generic names. Providers could theoretically prescribe both the brand and generic drug, increasing the risk for patient harm. A recent Annual Perspective discussed the benefits and limitations of CPOE with regard to patient safety.

Clinician burnout is increasingly recognized as a patient safety concern. This commentary summarizes the results of a consensus-building conference focused on physician burnout. The authors outline recommendations from the session to move the research base forward, including the need for collaboration to address the problem and examining the relationships between burnout, physician well-being, and care outcomes.