Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.

To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography.  To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.

… stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents …

Research has found that trigger tools perform poorly in cancer care. This cohort study comprised of adult patients undergoing treatment for breast, colorectal, lung or prostate cancer investigated the feasibility of a cancer-specific claims-based trigger tool to identify patients with potential adverse events. Results found that triggers affected 19% of patients during their initial year in treatment, and that trigger burden varied by disease, stage, and patient demographics. The most prevalent triggers were abnormal lab test results, blood transfusions, orders for non-contrast CT after chest radiation, and hypoxemia.

Preventable harm encompasses both physical injury and emotional harm to patients and families. Increasingly, the Agency for Healthcare Research and Quality, researchers, and patient advocacy groups have focused on studying and preventing emotional harm. Researchers convened a multidisciplinary expert group to identify best practices for enhancing respect and reducing emotional harm in health care. The group determined 25 strategies, including leading with an emphasis on respect and dignity, promoting accountability, partnering with patients, and supporting frontline staff. They provide a list of practical tactics to shift health care organizations toward a more respectful and just culture. A PSNet perspective examined how to accelerate organizational culture change in health care.

This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.

Chemotherapy errors can result in serious patient harm. This review summarized the evidence on chemotherapy errors. Most studies were performed in single-institution academic settings and few studies examined how health information technology affects patient outcomes.

Problems with the primary care–subspecialty referral process can lead to diagnostic delays. This focus group study of oncologists and primary care physicians examined insights from clinicians about communicating with other clinicians regarding delays in diagnosis. The analysis revealed fears about giving and receiving feedback during the cancer diagnostic process. Respondents had significant concern about affecting collegial relationships and expressed a desire for a formal mechanism for communication. Lack of clear responsibility was also viewed as a barrier to communication. The authors conclude that enhancing safety culture to promote open blame-free feedback among treating clinicians could enhance timeliness and accuracy of diagnosis.

Under the Centers for Medicare and Medicaid Service Hospital Readmissions Reduction Program, hospitals are subject to nonpayment if patients with certain medical conditions are readmitted. Research supports the effectiveness of this program in decreasing readmissions and some have argued for expansion to a hospital-wide readmission measure. Using Medicare claims data, investigators concluded that transitioning to a hospital-wide readmission measure would lead to greater penalties for safety-net hospitals compared to other hospitals, a concern that has been raised with regard to Medicare's Hospital-Acquired Condition Program.

Cancer care has been the setting for seminal, practice-changing errors. This retrospective study aimed to identify adverse events in cancer care through medical record review, using a random sample of breast, colorectal, and lung cancer cases from 2012. As with prior studies, physician investigators determined preventability and extent of harm. Over a third of patients experienced an adverse event, and about 32% of adverse events were deemed preventable. Most adverse events occurred in the inpatient setting. Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers and falls. The authors conclude that patient safety remains an important consideration for cancer care that merits further research and improvement efforts.

A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.

Trigger tools are an increasingly important method to detect adverse events. A trigger is a finding identified through structured data that signals a potential adverse event that should be examined by a member of the health care team. In this retrospective cohort study of patients treated for breast, lung, or colorectal cancer, investigators tested a trigger tool with 76 components. After narrowing it to the 49 best-performing triggers, the tool had a positive predictive value of 0.48, meaning that nearly half of the triggers truly represented adverse events. Almost 20% of the triggers represented preventable events. The authors suggest that automation of their trigger tool could lead to real-time identification of adverse events in oncology. A past PSNet interview featured David Classen, one of the pioneers of the trigger tool methodology for detecting adverse events.

Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety concerns to the attention of health care systems. Only 37 errors were reported during the study period of 17 months; most reports did not involve patient harm. As with prior studies of patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes reported was problems with diagnosis or advice from a provider. These results demonstrate the feasibility of implementing an incident reporting system for patients and families, and they underscore the need to focus on diagnostic safety in outpatient settings. A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care.

Delayed cancer diagnosis is a critical patient safety concern in primary care. Rectal bleeding is an important issue to recognize promptly, because it may be a symptom of colon cancer, for which delayed diagnosis can lead to worse outcomes. For this retrospective study, physician reviewers examined 438 abstracted medical records of patients with rectal bleeding to identify problems in the diagnostic process. In the majority of cases, they identified problems such as failure to elicit sufficient family history, incomplete physical examination performance or documentation, and lack of needed laboratory testing. Consistent with prior studies, failure to order laboratory testing and plan follow-up were associated with worse care quality. These findings emphasize the challenges of achieving timely and accurate diagnosis in the outpatient setting. In a related editorial, Hardeep Singh suggests that enhancing electronic health record capability and trigger tools could address diagnostic delays in primary care.

Checklists are widely utilized in health care to promote patient safety. Management of trauma patients is complex, and checklists may facilitate adherence to known standards of care. This pre–post study looked at the impact of the World Health Organization Trauma Care Checklist program across 11 hospitals in 9 countries. Researchers found that adherence to 18 out of 19 care process measures improved after the checklist program was implemented. Although investigators discerned no difference in mortality for the overall study population, they found a 50% reduction in mortality for patients with more severe trauma injuries after implementation of the program. A prior PSNet perspective discussed components of an effective checklist.

… The New England journal of medicine … N Engl J Med … The Centers for Medicare and Medicaid Service's policy on nonpayment for certain hospital readmissions has …

… safety in primary care settings. A recent AHRQ WebM&M interview and perspective discuss patient safety in …

This commentary describes the development of a quality and safety clinical fellowship curriculum which focused on identifying core competencies and then incorporating training for these principles in an operational setting. A companion article explores the implementation of this curriculum at hospitals affiliated with Harvard Medical School.

Prior studies have raised the concern that minorities may be at higher risk of adverse events while hospitalized. This systematic review sought to examine racial and ethnic disparities in studies of patient safety. The authors found that safety research does not uniformly include ethnically diverse populations or adjust for individual characteristics such as race, ethnicity, and income. Hospital-level variations (such as teaching status and percentage of minority patients) and geographic characteristics, both thought to affect disparities in health care outcomes, were not always reported or taken into account in the studies identified. In order to improve characterization of the role disparities play in adverse events, the authors call for research to include reporting of comorbid conditions, sociodemographic characteristics, differences in hospital levels, and geographic factors.