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.

Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.

The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.

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.

Patient safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the methods and results of an AHRQ Technical Brief, this commentary summarizes expert opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors outline patient safety practices relevant to the ambulatory setting and suggest activities to advance improvement efforts in outpatient care, such as measure development and use of health information technologies.

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.

Health care institutions are increasingly focused on providing high-value care and preventing overuse. In this study, researchers developed a validated High-Value Care Culture Survey and found that administering the survey at two large academic medical centers provided health care leaders with an opportunity to target their improvement efforts.

Patient safety research and commentary often focus on specialized care processes rather than medical wards. Exploring challenges to improving safety in the medical ward environment, this commentary outlines four strategies to address complexity of implementing initiatives in this setting.

Although financial incentives have been widely adopted, they may not lead to organizational improvements. This commentary raises concerns about including hospital mortality in incentive programs, since patient deaths do not necessarily mean poor quality care. The authors suggest that further research is needed to enhance accuracy of risk-adjusted mortality and to account for differences in patient treatment preferences.

Implementing standardized handoff processes has garnered attention as a strategy to improve patient safety. In this commentary, the authors apply cognitive load theory to handoff tasks to demonstrate how to improve handover bundles and enhance reliability.

Interdisciplinary team care interventions are increasingly common on medical wards, based partly on a widespread belief that these practices will improve efficiency and patient safety. This systematic review sought to evaluate the performance of hospital-based interdisciplinary teams on patient outcomes. The majority of studies have chosen length of stay, complications, readmission, or mortality rates as their primary outcomes, but interdisciplinary teams rarely seem to affect these traditional quality measures, which may be insensitive to teamwork improvements in care delivery. The authors call for establishing more relevant outcomes to evaluate interdisciplinary team interventions. An accompanying commentary notes that this systematic review provides an opportunity to highlight the potential harms of choosing the wrong metrics to evaluate an intervention, which can undermine a program's mission.