Delayed referrals from primary care providers to specialty care can lead to delayed diagnoses and patient harm. This retrospective analysis examined differences in timely versus delayed referrals for urgent skin cancer evaluations at one institution. Among 320 referrals occurring in 2018, 38% of evaluations occurred 31 days or more after the referral and nearly 11% of referrals were never completed. Delayed referrals were more common among patients who did not speak English and racial/ethnic minorities.

Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.

Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

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.

Patient complaints are associated with increased malpractice risk. This retrospective cohort study of more than 1300 ophthalmologists sought to determine whether ophthalmologist age was linked to likelihood of receiving unsolicited patient complaints. The authors found that unsolicited patient complaints occur less frequently among older ophthalmologists.

High-risk prescribing practices contribute to the widespread use of opioids. Analyzing Medicare data, this study found that most ophthalmologists wrote fewer than 10 opioid prescriptions per year, but a small group, concentrated in the Southern states, wrote more than 100 prescriptions annually. An Annual Perspective reviewed problematic prescribing practices that likely contribute to adverse events and described some promising practices to foster safer opioid use.