… policy response to the COVID-19 pandemic. … Halpern SD, Truog RD, Miller FG. Cognitive bias and public health policy …

This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.

This secondary data analysis of electronic health record (EHR) messages addressed to pathologists uncovered gaps in clinician-to-clinician communication. A range of clinicians used the EHR to ask clinical questions of pathologists, and pathologists largely did not use the EHR message inbox. The authors suggest that design and implementation of electronic tools should anticipate and address these potential safety problems.

In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.

In this chart review study, amended pathology reports with clinically significant patient results did not reliably reach treating clinicians. Despite prior studies highlighting the shortcomings of test results reporting, this patient safety issue persists.

Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.

This commentary explores how apologies and error disclosure are challenging for pathologists, due to their typical lack of direct contact with patients.

This commentary reviews direct disclosure of radiology errors to patients, barriers to those discussions, and tactics to improve them.