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The 2015 National Academies of Science, Engineering, and Medicine (NASEM) report Improving Diagnosis in Healthcare defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.” This review and interviews with subject matter experts explored how the NASEM definition of diagnostic error has been operationalized in the literature. Of the sixteen included studies, only five operationalized the definition and only three studied communicating with the patient. The authors recommend formulating a set of common approaches to operationalize each of the three components of the NASEM definition. Patients and family should be included in defining the construct of “communication to the patient.”

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) introduced a 16-hour shift limit for first-year residents. Recent studies found that these duty hour requirements did not yield significant differences in patient outcomes and the ACGME eliminated the shift limit for first-year residents in 2017. To assess the impact of work-hour limits on medical errors, this study prospectively followed two cohorts of resident physicians matched into US residency programs before (2002-2007) and after (2014-2016) the introduction of the work-hour limits. After adjustment for potential confounders, the work-hour limit was associated with decreased risk of resident-reported significant medical errors (32% risk reduction), reported preventable adverse events (34% risk reduction), and reported medical errors resulting in patient death (63% risk reduction).

Emergency medical services (EMS) clinicians must decide whether to transport patients to hospitals for emergency care, what level of emergency care they require, or to treat the patient at home and not transport to hospital. This analysis focused on patient safety incidents in Swedish prehospital care that occurred after 2015, following implementation of a protocol allowing EMS clinicians to triage patients to see-and-treat (non-conveyance) or see-and-convey elsewhere. Qualitative analysis of incident reports revealed three themes: assessment of patients, guidelines, and environment and organization. EMS clinicians deviated from the protocol in 34% of cases, putting patients at risk of inappropriate triage to see-and-treat.

Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.

Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.

Preventing falls is an ongoing patient safety priority. This article summarizes the relationship between prescription opioids and risk of falls among older adults, and provides recommendations around opioid prescribing and deprescribing.

Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.

The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.

Adverse drug events (ADEs) can result in serious patient harm. This systematic review of 62 studies found that hospitalizations related to ADEs ranged from 10 to 383 events per 100,000 people, whereas deaths due to ADEs ranged from 0.1 to 8 per 100,000 people.

When reported and investigated, near misses provide a unique learning opportunity for individuals and organizations. This scoping review of the literature on near misses identifies contributing factors (organizational, human, and technical); barriers and facilitators to reporting; and quality improvement projects to improve reporting of near misses.

Clinician well-being is increasingly seen as a quality and safety issue. This commentary discusses how systemic efforts must be built to enhance occupational well-being among clinicians. This approach discussed should consider both human factors and organizational design strategies to reduce burnout, cognitive overload, process frustration, and technology use.

Balancing autonomy and supervision is an ongoing challenge in medical training. This study explored how residents’ networking with senior physicians influences advice-seeking behaviors and medical errors. Findings suggest that residents made fewer errors when they consulted with fewer senior physicians overall and consulted more frequently with focal senior physicians (i.e., physicians sought out by other residents frequently for consults).

Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.