Despite increased focus on improving diagnosis as a major patient safety issue, measuring and defining diagnostic error remains challenging. A prior study showed that application of the Safer Dx Instrument—a structured tool to help identify diagnostic errors in the primary care setting—enabled improved detection of diagnostic errors compared to chart review alone. In this study, researchers tested the ability of the instrument to identify diagnostic errors in high-risk patients admitted to the pediatric intensive care unit. Out of 214 high-risk patient charts, 26 were found to contain a diagnostic error. Two clinicians independently reviewed the records using the tool and reviewer agreement was 93.6%, suggesting that the Safer Dx Instrument may be useful in additional clinical settings. An Annual Perspective discussed the challenges associated with diagnostic error.

Medication reconciliation—the process of cross-checking patients' medication lists to correct errors and inadvertent omissions—was named a National Patient Safety Goal in 2005. Despite this, no consensus exists yet as to the best method of accomplishing medication reconciliation. This description of the process of implementing medication reconciliation at an urban public hospital includes much information that will be helpful for hospitals undertaking a similar process. The authors detail the barriers faced in developing the system (which was incorporated into an existing computerized order entry system), encouraging use of the system, and improving it based on user feedback. Prior research in this area has demonstrated the effectiveness of pharmacists at carrying out medication reconciliation.

This commentary discusses recommendations from the Veterans Health Administration on disclosure of medical errors to patients.