Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.

… J Am Med Inform Assoc … Patients and families are encouraged … safety through OurDX: a previsit online engagement tool. J Am Med Inform Assoc. Epub 2023 Jan 24 10.1093/jamia/ocad003 …

… Jt Comm J Qual Patient Saf … Leadership across all levels of a health … engagement, and healthcare worker well-being. Jt Comm J Qual Patient Saf. Epub 2022 Dec 23. 10.1016/j.jcjq.2022.12.006 …

… of AI that affect reliability. … Classen DC, Longhurst C, Thomas EJ. Bending the patient safety curve: how much can AI …

Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.

… the effects of COVID-19 on healthcare worker well-being. … Sexton JB, Adair KC, Proulx J, et al. Emotional exhaustion among US health care workers …

… J Patient Saf. … Psychological safety (PS) is integral to … metric for the ability to speak up in healthcare settings. J Patient Saf. 2022;18(6):513-520. …

Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental – rather than performance – goals).

Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.

Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.

… J Perinatol … Patients in the neonatal intensive care unit … seven days of admission was 6.2%. … Shafer GJ, Singh H, Thomas EJ, et al. Frequency of diagnostic errors in the … intensive care unit: a retrospective cohort study. J Perinatol. Epub 2022 Mar 4. doi: 10.1038/s41372-022-01359-9. …

Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.

… take contextual factors into consideration. … Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the …

This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.

… Jt Comm J Qual Patient Saf … Safety WalkRounds involve health care … climate nine-months after implementation.   … Klimmeck S, Sexton BJ, Schwendimann R. Changes in safety and teamwork climate after adding …

… Jt Comm J Qual Patient Saf … Health system leadership practices can …

… J Perinatol … High levels of healthcare worker (HCW) burnout … and patient safety climate amid the COVID-19 pandemic.  J Perinatol . 2021;41(5):961-969. …

… and drivers of safety culture. … Bisbey TM, Kilcullen MP, Thomas EJ, et al. Safety culture: an integration of existing …