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.

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.

Provider bias may impact the pain management patients receive post-operatively. This review presents recent findings on the types and amounts of pain management patients receive. Results suggest women and people of color receive less pain medication despite reporting higher pain scores. Results regarding socio-economic status and English language proficiency bias are mixed. Implicit bias training, prescribing guidelines for all patients, and culturally competent pain management scales have all been suggested as ways to reduce provider bias and improve pain management.

Emergency department triage nurses use their knowledge, experience, expertise, and critical thinking skills to prioritize patients by severity, ensuring the sickest patients are seen first. This study sought to identify cognitive biases that may negatively impact nurses' triage decision making. In a scenario describing a patient at Emergency Severity Index (ESI) level 1, the highest level, only 51% of nurses selected the cognitively unbiased triage response.

Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.

Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals outperforms the judgment of a single individual. This study sought to determine if real-time information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals within the group. Individual accuracy did improve, suggesting real-time information-sharing between physicians could improve diagnostic decision-making in practice, although additional research is required.

Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).

Illegible prescriptions can cause pharmacists to dispense incorrect medications resulting in patient harm. This review identified 15 studies on illegible prescriptions. Most of the studies were more than 10 years old and the authors acknowledge the advent of computerized provider order entry (CPOE) has reduced incidence of illegible prescriptions. However, CPOE relies on highly functional information technology systems which may be cost-prohibitive for some countries.

Clerkship directors indicate clinical and diagnostic reasoning education should be included in medical school curricula, but up to half of programs do not offer it. This article describes the development, implementation, and evaluation of a diagnostic reasoning virtual training for pre-clinical medical students. Students reported increased confidence and understanding of diagnostic reasoning.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

I-PASS, a structured hand-off tool, can reduce preventable adverse events during transitions of care. Previously published studies have shown that Patient and Family-Centered (PFC) I-PASS rounds reduced preventable and non-preventable adverse events (AE) in hospitalized children. This study presents additional analysis, comparing AE rates in children with complex chronic conditions (CCC) to those without. Results show a reduction in AE in both groups, with no statistically significant differences between the groups, suggesting PFC I-PASS may be generalizable to broader groups of patients without needing modification.

Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.

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… with a 43% decline in infections. … McCleskey SG, Shek L, Grein J, et al. Economic evaluation of quality improvement …

Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.