Improving diagnostic quality is a patient safety priority. In this study, researchers used audio-recorded encounters, clinical note review, and interviews in order to evaluate a tool assessing key elements of diagnostic quality during clinical encounters. Many elements were reliably included in the clinical note or encounter transcript (e.g., follow-up contingencies, red flags) but other elements were often missing (e.g., psychosocial/contextual information). The researchers found that burnout was more common among physicians recording fewer key diagnostic elements.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

… English and racial/ethnic minorities. … Pagani K,  Lukac D, Olbricht SM, et al. Urgent referrals from primary care to …

Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.

… minimization of overrides and workarounds. … Lambert BL, Schiff GD. RaDonda Vaught, medication safety, and the …

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

… Version 1.0 is now available. … Bradford A, Shahid U, Schiff GD, et al. Development and usability testing of the …

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.

Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.

… that affect the safety of telediagnosis in primary care. … Willis JS, Tyler C, Jr., Schiff GD, et al. Ensuring primary care diagnostic quality in …

… of diagnostic process safety. … Olson APJ, Linzer M, Schiff GD. J Gen Intern Med. Epub 2021 Feb 11. …

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.  

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.

Evidence suggests that computerized provider order entry (CPOE) systems improve medication safety by mitigating prescribing errors. However, CPOE systems may contribute to errors when user-centered design is not taken into account. In this study, researchers standardized the assessment of 10 distinct inpatient and ambulatory CPOE systems across 6 health care institutions to determine how variation in drug name display may increase the risk of medication errors. Using test patient scenarios, they found significant variation in drug name display, including inconsistencies with regard to the display of brand and generic names. Providers could theoretically prescribe both the brand and generic drug, increasing the risk for patient harm. A recent Annual Perspective discussed the benefits and limitations of CPOE with regard to patient safety.

Electronic health record implementation has improved safety through mechanisms such as computerized provider order entry (CPOE), but it has also had unintended adverse effects on patient safety. Reviewing incident reports from the US Pharmacopeia where CPOE was a contributing factor, this study sought to determine whether current CPOE systems are vulnerable to similar errors. Investigators then entered potentially problematic medication orders in various CPOE systems using a simulated approach. They encountered multiple usability hurdles including confusion with critical and irrelevant alerts, workflow issues, and variability in how orders were entered. These results demonstrate the need for robust independent usability testing of CPOE within electronic health records to support patient safety.

This editorial discusses the potential of using electronic screening tools, known as triggers, to detect and prevent diagnostic errors.