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.

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.

… stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents … involved in the error. … Prentice JC, Bell SK, Thomas EJ, et al. Association of open communication and the …

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.

A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.

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.

In order to characterize outpatient safety, this study of small- and medium-sized ambulatory clinics surveyed administrators about organizational safety and staff about communication and existing safety processes. Administrators reported a lack of safety systems, consistent with prior discussion of ambulatory settings. As with earlier research in hospitals, frontline staff describe difficulty speaking up about errors. Staff responses suggested that insufficient time to manage their workload leads to safety problems, echoing a recent focus group study of physicians. Respondents also reported weaknesses in outpatient referral processes. Overall, staff and administrators in ambulatory practices continue to identify gaps in care that contribute to adverse events, highlighting opportunities to improve safety in primary care settings. A recent AHRQ WebM&M interview and perspective discuss patient safety in ambulatory care.

Diagnostic errors are a common cause of patient harm in ambulatory care. Although such errors have often been ascribed to cognitive biases, this study highlights physicians' concerns that health system structures and communication are major drivers of delayed and missed diagnoses. Focus group discussions involving 25 outpatient physicians—primarily from internal and family medicine—identified multiple potential sources of diagnostic errors, including insufficient information availability, disjointed workflows, and poor communication among providers and with patients. This study underscores many overlapping issues that will need to be addressed to meaningfully enhance diagnostic accuracy. In a recent AHRQ WebM&M interview, Dr. Urmimala Sarkar, the lead author of this study, discussed patient safety in the ambulatory setting.

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.