Checklists are used to improve patient outcomes in a wide variety of clinical settings and processes, such as childbirth, surgery, and diagnosis. This review applied the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) human factors framework to 25 diagnostic checklists. Checklists were characterized within the three primary components (work systems, processes, and outcomes) and subcomponents. Checklists addressing the Task subcomponent were associated with a reduction in diagnostic errors. Several subcomponents were not addressed (e.g. External Environment, Organization) and present an opportunity for future research.

Many hospitals are implementing programs to support clinicians involved in adverse events (‘second victims’). Researchers interviewed 12 representatives of second victim programs in the United States about the experiences of their programs. The article discusses representative feedback regarding the importance of identifying a need for second victim programs and services, perceived challenges to program success, structural changes after program implementation, and insights for success.   

The COVID-19 pandemic has exacerbated racial and ethnic disparities in healthcare. This study used registry data to examine racial and ethnic disparities in post-discharge outcomes among patients hospitalized with COVID-19. Findings indicate that Black patients may be more vulnerable to COVID-19-related complications (e.g., higher 60-day readmission rates) and extended recovery periods (e.g., longest delays in returning to work).

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  

This article describes the use of a case-based simulation to explore how physicians reason, create differential diagnoses, and ultimately achieve a correct diagnosis. Participating physicians who achieved the correct diagnosis (herpes zoster) utilized systems-based or anatomic approaches, rather than focuses on life-threatening diagnoses alone, and employed debiasing strategies.

This article discusses key elements to preparing hospitals for an influx of COVID-19 patients, including a robust hospital preparedness plan, appropriate protections for frontline healthcare staff, clinical guidelines for use of scarce resources such as ventilators, and a comprehensive communication strategy for internal and external stakeholders.

Prior research has found that diagnostic errors comprise approximately one-fifth of preventable errors among hospitalized patients. Academic clinical care poses unique risks for diagnostic error because the frontline providers are residents and medical students. Thus, accurate diagnosis relies on robust communication between learners and their supervisors. A team of social scientists and clinicians conducted an ethnographic study of physicians on academic inpatient rounds to identify barriers to timely and correct diagnoses. They found that reliance on one-way communication methods and insufficient face-to-face interactions with patients and consultants hindered effective diagnostic decision-making. Additionally, the electronic health record led to data overload and data fragmentation. The authors offer concrete suggestions for more clinician- and patient-centered technical tools. A WebM&M commentary discussed a diagnostic error involving learners in psychiatry.

This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.

The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.

This ethnographic study examined the process of making a diagnosis among academic inpatient medical teams. Investigators observed that diagnosis requires dialogue within team, needed data is often not available, and distractions and time pressure are frequent. These observations may inform future interventions to improve timeliness and accuracy of diagnosis.

Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.

This commentary draws parallels between a misinterpreted military training exercise with diagnostic errors to describe how premature closure and overreliance on technology can result in mistakes both on the battlefield and in diagnosis.

The July Effect is the widely held belief that the quality of care delivered in academic medical centers decreases during the summer months due to the arrival of new trainee physicians. This survey found that most academic residency leaders attempt to mitigate errors in July, utilizing strategies such as handoff education, electronic health records training, and employing attending physicians with high teaching ratings to work in July. However, these results should be interpreted with caution in light of the low survey response rate (16%).

… improvement strategy. … Petrilli CM, Del Valle J, Chopra V. Why July Matters.  Acad Med . 2016;91(7):910-912. …

Mentors can serve as coaches to help improve student performance, but they may also demonstrate unprofessional behaviors. Describing dysfunctional mentorship behaviors that can affect success in academic medicine, this editorial explains how to recognize and address such problematic relationships.

Catheter-associated infections are common, and largely preventable, adverse events. Though incidence of these events has declined due to intensive safety efforts, one factor contributing to intravenous catheter infections is the failure to remove unnecessary central venous catheters (CVCs). This study sought to determine whether inpatient physicians know which of their patients have CVCs in place by comparing physician response to direct observation of each patient. Physicians were unaware of CVCs in about 20% of the cases examined. Trainee physicians were more likely to be aware of a CVC than teaching attending physicians or hospitalists, and critical care physicians were more likely to know about a CVC than general medicine physicians. These findings suggest that interventions to reduce CVC-associated infections should address clinician awareness of CVCs. An AHRQ WebM&M commentary discusses best practices for removing CVCs.

Alarm fatigue refers to clinicians' tendency to ignore safety alerts if they are too frequent or perceived to be clinically irrelevant. This commentary describes what makes an alarm effective, how alarms can contribute to adverse events, and strategies to reduce risks.