Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.

This article reviews strategies to mitigate transmission of COVID-19 among patients with cancer and for the healthcare workers providing care to those patients. The authors recommend several approaches ensure patient safety, including COVID-19 prescreening/screening via telemedicine, greater utilization of tele-oncology, limiting surgeries and procedures to only essential, urgent, or emergent cases, and switching therapies to oral (versus infusion) when possible. They also propose measures focused on healthcare worker safety, including appropriate use of personal protective equipment (PPE), use of daily screening tools and/or temperature checks, greater use of telework and limited onsite staff, and clear stay-at-home and return-to-work guidelines.

To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography.  To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.

This article describes results of a cross-sectional recontact survey of Massachusetts residents on the persisting impacts of medical errors. Over half of respondents on the self-reporting a medical error 3-6 years ago survey stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents reported a loss of trust after the medical error. Logistical regression analyses, controlling for error severity, suggests that open communication can reduce persistent emotional impacts and avoidance of doctors/facilities involved in the error.

Research has found that trigger tools perform poorly in cancer care. This cohort study comprised of adult patients undergoing treatment for breast, colorectal, lung or prostate cancer investigated the feasibility of a cancer-specific claims-based trigger tool to identify patients with potential adverse events. Results found that triggers affected 19% of patients during their initial year in treatment, and that trigger burden varied by disease, stage, and patient demographics. The most prevalent triggers were abnormal lab test results, blood transfusions, orders for non-contrast CT after chest radiation, and hypoxemia.

This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.

Chemotherapy errors can result in serious patient harm. This review summarized the evidence on chemotherapy errors. Most studies were performed in single-institution academic settings and few studies examined how health information technology affects patient outcomes.

Problems with the primary care–subspecialty referral process can lead to diagnostic delays. This focus group study of oncologists and primary care physicians examined insights from clinicians about communicating with other clinicians regarding delays in diagnosis. The analysis revealed fears about giving and receiving feedback during the cancer diagnostic process. Respondents had significant concern about affecting collegial relationships and expressed a desire for a formal mechanism for communication. Lack of clear responsibility was also viewed as a barrier to communication. The authors conclude that enhancing safety culture to promote open blame-free feedback among treating clinicians could enhance timeliness and accuracy of diagnosis.

Cancer care has been the setting for seminal, practice-changing errors. This retrospective study aimed to identify adverse events in cancer care through medical record review, using a random sample of breast, colorectal, and lung cancer cases from 2012. As with prior studies, physician investigators determined preventability and extent of harm. Over a third of patients experienced an adverse event, and about 32% of adverse events were deemed preventable. Most adverse events occurred in the inpatient setting. Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers and falls. The authors conclude that patient safety remains an important consideration for cancer care that merits further research and improvement efforts.

Trigger tools are an increasingly important method to detect adverse events. A trigger is a finding identified through structured data that signals a potential adverse event that should be examined by a member of the health care team. In this retrospective cohort study of patients treated for breast, lung, or colorectal cancer, investigators tested a trigger tool with 76 components. After narrowing it to the 49 best-performing triggers, the tool had a positive predictive value of 0.48, meaning that nearly half of the triggers truly represented adverse events. Almost 20% of the triggers represented preventable events. The authors suggest that automation of their trigger tool could lead to real-time identification of adverse events in oncology. A past PSNet interview featured David Classen, one of the pioneers of the trigger tool methodology for detecting adverse events.

Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety concerns to the attention of health care systems. Only 37 errors were reported during the study period of 17 months; most reports did not involve patient harm. As with prior studies of patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes reported was problems with diagnosis or advice from a provider. These results demonstrate the feasibility of implementing an incident reporting system for patients and families, and they underscore the need to focus on diagnostic safety in outpatient settings. A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care.

Delayed cancer diagnosis is a critical patient safety concern in primary care. Rectal bleeding is an important issue to recognize promptly, because it may be a symptom of colon cancer, for which delayed diagnosis can lead to worse outcomes. For this retrospective study, physician reviewers examined 438 abstracted medical records of patients with rectal bleeding to identify problems in the diagnostic process. In the majority of cases, they identified problems such as failure to elicit sufficient family history, incomplete physical examination performance or documentation, and lack of needed laboratory testing. Consistent with prior studies, failure to order laboratory testing and plan follow-up were associated with worse care quality. These findings emphasize the challenges of achieving timely and accurate diagnosis in the outpatient setting. In a related editorial, Hardeep Singh suggests that enhancing electronic health record capability and trigger tools could address diagnostic delays in primary care.

Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and 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 commentary describes the development of a quality and safety clinical fellowship curriculum which focused on identifying core competencies and then incorporating training for these principles in an operational setting. A companion article explores the implementation of this curriculum at hospitals affiliated with Harvard Medical School.

Prior studies have raised the concern that minorities may be at higher risk of adverse events while hospitalized. This systematic review sought to examine racial and ethnic disparities in studies of patient safety. The authors found that safety research does not uniformly include ethnically diverse populations or adjust for individual characteristics such as race, ethnicity, and income. Hospital-level variations (such as teaching status and percentage of minority patients) and geographic characteristics, both thought to affect disparities in health care outcomes, were not always reported or taken into account in the studies identified. In order to improve characterization of the role disparities play in adverse events, the authors call for research to include reporting of comorbid conditions, sociodemographic characteristics, differences in hospital levels, and geographic factors.

A recent systematic review found that better patient experiences of care are associated with improved patient safety and quality of care. This survey of more than 2500 adults discharged from 16 hospitals in Massachusetts adds to our understanding of this relationship. Patients who self-reported having experienced an adverse event (AE) while hospitalized rated the overall quality of hospital care lower, but this finding was primarily among patients who did not report that the AE they experienced was explicitly disclosed to them. Among patients who experienced an AE, it appeared that patient satisfaction was highest (and nearly equal to satisfaction of patients with error-free hospitalizations) when the error was disclosed, the patients were engaged in their own care, and discharge was perceived as timely. These findings imply that even when patients experience complications, "service recovery" efforts, such as formal error disclosure programs, can positively affect patients' perceptions of the care quality.

Print news media describes errors in cancer care from patient or legal perspectives more frequently than from clinician or safety expert perspectives. A significant proportion of articles ascribe blame to clinicians and hospital systems and do not discuss systems approaches.

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).