The COVID-19 pandemic resulted in many changes to the delivery of healthcare. Using data submitted to one Patient Safety Organization, this study examined patient safety events and concerns related to proning patients during the COVID-19 pandemic. Issues identified included medical device-related pressure injuries and device dislodgement, concerns with care delivery, staffing levels, and acuity issues.

Although improving diagnosis is a critical patient safety priority, few interventions have been tested, especially in outpatient settings. This pre–post study examined whether a "diagnostic pause," a type of checklist, could improve outpatient diagnostic safety. The team used an electronic health record–based automated trigger to identify patients at risk for missed diagnosis—patients presenting for an urgent care visit who had a previous urgent care visit within 2 weeks. At the second visit, the clinician received a prompt to reflect on the diagnosis and a short survey about how the prompt affected their actions. Participating clinicians responded to about 60% of the prompts they received and reported changing their actions 13% of the time. The authors conclude that identifying challenging diagnoses and supplementing clinicians' current diagnostic pathways requires further research.

Delirium is considered a patient safety problem that can be prevented with specific care practices in the hospital. This commentary reviews an incident involving a patient with delirium and describes evidence-based practices to manage the condition, such as avoiding medications that precipitate confusion, maintaining an environment that fosters orientation (light during the day, dark at night), and use of low-dose antipsychotic medications on a short-term basis if nonpharmacological approaches fail. The authors emphasize the importance of timely diagnosis and treatment of delirium.

Residency training presents challenges to patient safety, including increased handoffs due to duty-hour reform. While residents are completing inpatient and outpatient training simultaneously, providing outpatients with continuity of care poses an additional complication. In this pre-post survey study, investigators found that separating inpatient and outpatient responsibilities for residents enhanced their perceptions of patient safety in both settings. This intervention also improved patient continuity (the proportion of visits for which residents saw their own patients); heightened continuity is thought to foster timely and accurate diagnosis. This study offers a replicable intervention to address some patient safety risks associated with medical residency. A previous WebM&M commentary discusses safety hazards and educational challenges related to academic year-end transfers.

Engaging residents and fellows in quality and safety programs is a recognized strategy to address a gap in medical education. This commentary describes a six-factor framework to integrate safety concepts into graduate medical education curriculum focusing on organizational elements such as culture, interprofessional learning, and faculty development.

In the outpatient setting, patients frequently experience adverse events between clinician visits, and many of these may go undetected. This randomized controlled trial sought to evaluate a novel method of engaging patients in safety in order to identify and prevent adverse drug events (ADEs) in outpatients. Patients who were enrolled in an online patient portal (which allowed them to view their own laboratory results and communicate directly with their clinicians) were randomized to be sent automated queries after receiving a new prescription. The queries confirmed whether the prescription was filled and asked questions to detect potential ADEs. Nearly half of the intervention group patients responded to a query and many prescription problems were discovered, but the overall rate of ADEs was no different than the control group (which was enrolled in the portal but did not receive the medication safety messages).

Systems changes to facilitate verbal communication combined with a tool to improve written signouts resulted in higher quality handoffs in an internal medicine residency program.

This national survey evaluated the scope and nature of quality improvement and patient safety activities within academic departments of medicine and identified a number of potential areas for progress.

A rapid response team model that relied on clinical triggers to summon the primary team caring for the patient—rather than a dedicated, separate team—resulted in sustained reductions in unexpected inpatient mortality over a 4-year period.

E-prescribing is a growing solution to prevent medication errors, with insurers rewarding the practice and high-risk settings adopting the technology. This study surveyed more than 180 ambulatory providers who use e-prescribing systems and found that respondents believed the system improved the quality of care delivered, prevented errors, and enhanced both patient satisfaction and clinical efficiency. However, less than half the respondents were satisfied with the drug interaction and allergy alerts. The authors advocate for better design of alert systems to prevent alert fatigue yet promote safe prescribing practices. The challenges of implementing effective medication decision support systems are discussed in an AHRQ WebM&M perspective.

The full potential of computerized provider order entry (CPOE) systems to prevent potentially harmful errors may require concomitant use of decision support–alerts or reminders for providers. This analysis of over 270,000 prescriptions from a commercial outpatient prescribing application found that more than 400 adverse drug events (ADEs) were likely prevented by such alerts. More than 300 alerts were required to prevent one ADE, so in order to combat alert fatigue, the authors recommend reducing or eliminating alerts with little clinical value. A related editorial discusses the current state of electronic prescribing systems in the context of recent policy initiatives. The phenomenon of alert fatigue and other unintended consequences of CPOE are discussed in an AHRQ WebM&M commentary.

The safety benefit of computerized provider order entry systems rests in large part on the ability to provide decision support—for example, alerts that warn clinicians about potential drug–drug interactions. However, this study of more than 200,000 alerts generated by a commercial outpatient electronic prescribing system found that clinicians rejected the vast majority of alerts, even those representing "high-severity" drug interactions. The study also found evidence of "alert fatigue," where heavier users of the system were more likely to reject drug interaction warnings. This phenomenon has been previously documented as one of several types of unintended consequences of computerized order entry. Improvements in the decision support system, such as tiering alerts, have been associated with increased acceptance of warnings.

Prior research has demonstrated that problems with service quality—for example, waits and delays, poor communication, and poor amenities—are common in hospitals. While patients tend to identify these issues when surveyed about problems they perceive with the quality of care they receive, no relationship has yet been identified between service quality and patient safety. This AHRQ-funded study used retrospective chart review to correlate patients' complaints of poor service quality with documented adverse events and found that patient-reported instances of poor service quality were associated with double the risk of medical errors. The authors hypothesize that some factors associated with the quality of medical care, such as communication between team members, may also be reflected in service quality.

The authors describe a medication safety communication initiative that sent e-mail messages to patients regarding new or changed prescriptions. The authors conclude that the system helped physicians identify and address adverse drug events.

The investigators interviewed patients during hospitalization and after discharge to identify service quality deficiencies and found delays, communication, and environmental issues to be the most common problems.

… interpretations of quality. … Weingart SN; Iezzoni LI; Davis RB; Palmer RH; Cahalane M; Hamel MB; Mukamal K; …

In this prospective study, investigators used post-discharge interviews and medical record review to capture the frequency and types of adverse events as reported by patients. The authors enrolled 228 patients hospitalized on an inpatient medical service and discovered that 8% reported suffering an adverse event. Discussion includes detailed analysis of the reported events and comparison to those noted in the medical record and from hospital incident reports. The authors conclude that engaging patients in the identification of medical errors may offer an additional and equally important approach to improving patient safety.