Resident preparedness to provide safe care without supervision has been found to be inconsistent across health care. This commentary explains how written tests can fail to uncover these gaps in competency and suggests that current checklists for basic procedural skills are insufficient for assessing performance. The authors recommend an itemized assessment tool with a sharper focus on competency and review their experience with implementing one.

Failure to appreciate the role of contextual factors—such as patients' access to care or social support—can result in diagnostic errors. In this analysis of data from a prior study, failure to appropriately individualize care based on contextual factors led to substantial excess costs, often due to prescribing unnecessary medications. The investigators also make the important point that most of these errors would not have been detected by standard quality measures for outpatient care.

Focus groups identified factors that promoted both effective and ineffective communication between nurses and physicians.

The landmark Institute of Medicine report on patient safety categorized inappropriate plans of care as a medical error. This broad classification encompassed decision-making errors by clinicians that included diagnostic errors but also the notion of contextual errors. The latter are those that occur because of inattention to patient context such as environment, behavior, economic situation, or access to care and social support. This study used unannounced standardized patients who acted out four clinical scenarios presenting with biomedical and contextual complicating factors. Attending physicians probed fewer contextual red flags than biomedical ones and provided error-free plans of care in 73% of the uncomplicated encounters, 22% of the contextually complicated encounters, and only 9% of the combined biomedically and contextually complicated encounters. The authors advocate for greater attention and performance metrics to assess how well providers deliver individualized patient care plans based on probed contextual factors.

This study describes a methodology for measuring physician performance and focuses on the ability to expose forms of contextual error.