Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

COVID-19 restrictions and patient safety concerns have greatly expanded the use of telehealth and virtual visits. Through patient satisfaction surveys and patient complaints, this US hospital evaluated the quality and safety of virtual visits in March and April of 2020. Five patient complaints were submitted during this timeframe and overall patient satisfaction remained high. Safety and quality risks were identified (e.g., diagnostic error) and best practices were established.

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.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.

Clinical decision support (CDS) systems are intended to support diagnosis and therapeutic processes of care. This position paper defines adaptive CDS as “systems that can learn and change performance over time, incorporate new clinical evidence, data types, data sources, and methods for interpreting data.” Recommendations for the effective management and monitoring of adaptive CDS are outlined.

Quality measurement is increasingly being incorporated into policies outlining healthcare provider reimbursement. This study compared quality measure calculations between an individual electronic health record (EHR) source and the same EHR source combined with health information exchange (HIE) data. The results show that adding HIE data changed 15% of quality measure calculations. The authors suggest that incorporating HIE data into reimbursement programs could promote more accurate and representative quality measurement.

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 article describes the implementation of a new system for identifying, communicating, and resolving safety reports pertaining to COVID-19 in one academic tertiary care center through the use of electronic safety reporting systems and daily huddles.

This article describes the development of a COVID-19 exposure disclosure checklist which reflects five core competencies for effective disclosure conversations with patients and families. The authors discuss disclosure with persons who have limited English proficiency, undocumented and immigrant patients, and patients with specific health needs.

A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.

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.

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.

This retrospective review of nearly 900 incident reports related to diagnostic imaging found that the most common type of safety problem was linked to the imaging procedure. Events associated with communicating abnormal results were less common but had a higher potential to harm patients. Most events had multiple contributing factors.

Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.

… associated with computerized decision support. … Wright A; McEvoy DS; Aaron S; McCoy AB; Amato MG; Kim H; Ai A; Cimino JJ; Desai BR; El-Kareh R; Galanter W; Longhurst CA; Malhotra S; …

Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.

This simulation study compared computerized medication order entry between two commercial electronic health records and a prototype designed for safe prescribing. Physicians using the prototype had fewer errors compared to either commercial platform, highlighting the need to improve electronic health record usability in order to enhance medication safety.

This direct observation and interview study examined safety activities associated with electronic health records. The study team identified decision making, organizational learning, and frontline user engagement (including clinical decision support and training) as the three critical areas for safe use of electronic health records.