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Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.

Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.

Implicit and explicit bias can reduce the effectiveness and safety of care. Based on a review of the literature, the authors conclude that the strain placed on provider resources, staff, and supplies by the COVID-19 pandemic may exacerbate implicit bias among pediatric providers. The authors discuss implicit bias at the individual, organizational, educational, and research levels, provide specific calls to action for pediatric healthcare providers, and discuss the role of pediatric psychologists in supporting other providers.

The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.

The COVID-19 pandemic has led to wide-ranging changes to health care delivery, some of which may negatively impact patient outcomes.The authors use a syndemic perspective to discuss existing challenges interfering with diagnosis (structural, socioeconomic, patient-related, and provider-related), how the COVID-19 pandemic has exacerbated those challenges, and strategies related to nurse practitioners and community health workers to improve diagnosis.  

Prescribing medications for indications that are not approved by the Food and Drug Administration (FDA) is common but poses a risk for medication errors. The authors of this study used simulation modeling to explore the influence of physician personal preference on off-label medication use during the COVID-19 pandemic.  

Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.

COVID-19 restrictions and patient concerns have expanded use of telehealth. This study found virtual urgent care services to be an effective strategy for patient care during the pandemic.  

The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery. 

COVID-19 restrictions and patient concerns have expanded access to telemedicine worldwide. This review examines the use of telemedicine in surgical services. The authors found it to be a safe care modality for low-risk patients receiving low-risk procedures. They found that telemedicine in surgical services evidence base is expanding and its value is built on local, real-time approaches that involve services designed to consider patient needs and comfort.