COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.

Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.

This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.

Health care institutions are increasingly focused on teaching quality improvement and patient safety to both faculty and trainees. This study describes the implementation of an online course comprised of three quizzes to teach important concepts related to quality improvement, patient safety, and care transitions across five academic medical centers.

Insufficient follow-up with patients after hospitalization hinders identification of diagnostic or treatment errors. This commentary discusses the results of an intervention that incorporated a structured process for residents to gather information and reflect on patient status for postdischarge follow-up.

Patients hospitalized and cared for by an overnight physician, known as "holdover admissions," are increasingly common due to duty hours limitations, and they necessitate handoffs between admitting physicians and the new primary medical team. This qualitative study identified unmet needs in holdover handoffs, including assessment of diagnostic uncertainty, standardization, and feedback. The authors call for more scrutiny of holdover handoffs.

Primary care physicians at an academic medical center continued to speak up about concerns regarding the quality of communication they received from inpatient teams even after implementation of a shared electronic medical record. They also expressed a desire for increased direct communication at discharge for complex patients and patients with detailed follow-up needs.

This narrative review found that while computerized provider order entry combined with clinical decision support systems effectively prevented medication prescribing errors, there was no clear effect on clinical adverse drug event rates. This finding may be due to alert fatigue and other unintended consequences of the technology.

Despite an intense policy focus on preventing readmissions and adverse events after hospital discharge, this systematic review found only limited evidence to support the use of relatively high-intensity approaches to improving transitional care. This AHRQ-funded study was published as part of a special patient safety supplement in the Annals of Internal Medicine.

The beginning of residency training for new interns has long been rumored to result in preventable harm for patients, a phenomenon known as the "July Effect" in the US and by the more macabre term "August killing season" in the UK. However, prior studies have reached conflicting conclusions about whether the "July Effect" truly exists. This systematic review of 39 studies provides the first comprehensive evidence that being hospitalized in July may actually be harmful, as a subset of larger and higher quality studies did find that mortality increased and efficiency of care decreased in association with new residents assuming their duties. Unfortunately, most studies included in the review had methodological flaws, meaning that the exact degree of harm could not be quantified.

This study found that dictating discharge summaries was a task residents commonly completed after hours. With greater work hour restrictions on the horizon, strategies to manage indirect patient care activities may include using them as opportunities to teach system-based practice improvement.

A 2008 policy change by the Centers for Medicare and Medicaid Services (CMS) eliminated reimbursement for certain preventable errors, including selected never events and hospital-acquired infections. The impact of the policy was debated, including the ability of providers and systems to accurately identify conditions present on admission. This study involved an educational intervention to assess the policy's impact on clinical practice among trainees. In a series of presented clinical vignettes, members of the intervention group, who received education about the new policy as part of the study, were less likely than participants who received no such education to select the most clinically appropriate response. While all the trainees acknowledged responsibility to understand CMS documentation rules and felt poorly trained to do so, their responses to the vignettes raised concern about the potential harm and unintended consequences caused by unnecessary testing and procedures that may result from the policy. The implications of the CMS policy are further discussed in an AHRQ WebM&M perspective.

This survey characterizes the types of rapid response systems in academic tertiary care hospitals in the United States and discusses barriers to implementation as well as successes achieved by the teams.

Patient safety improvement initiatives are often chosen in the context of an existing tension between taking an evidence-based approach versus a practical one. This commentary provides a framework for choosing various interventions with a particular focus on what hospitalists should target for implementation. The authors advocate for a "balanced diet" approach in combining: (1) important practices with strong evidence (e.g., prevention of catheter-related blood stream infections), (2) momentum-generating projects (e.g., executive walk rounds), and (3) system-level interventions (e.g., computerized physician order entry [CPOE]). A previous AHRQ WebM&M perspective addresses how to interpret the patient safety literature.

… populations that may benefit most from RRS availability. … Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. …