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Agency for Healthcare Research and Quality. 

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.
Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;Epub May 31.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Lam JYJ, Barras M, Scott IA, et al. Drugs Aging. 2022;39:333-353.
Patient characteristics such as age, comorbidities and frailty can increase risk for medication errors. This scoping review shows that studies evaluating medication harm in frail patients are largely limited the methodological quality and inadequate reporting. The authors discuss the need for more robust studies examining this relationship, including the effect of polypharmacy.
Baim-Lance A, Ferreira KB, Cohen HJ, et al. J Gen Intern Med. 2022;Epub May 17.
When serious adverse events such as death are reported, they are typically associated with poor patient safety. In some fields of care, however, such as palliative care, deaths are expected and not necessarily an indicator of poor quality. This commentary describes how serious and non-serious adverse events (SAEs/AEs) are currently defined and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the new proposed approach is presented.
Mortensen M, Naustdal KI, Uibu E, et al. BMJ Open Qual. 2022;11:e001751.
A 2011 systematic review identified nine tools to assess patient safety competence in nurses. This review identified multiple instruments released since that review; the most frequently used was the Health Professional Education in Patient Safety Survey (H-PEPSS). The authors suggest future research should consider including ethics in patient safety and responsiveness to change over time.
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 5.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
Salema N-E, Bell BG, Marsden K, et al. BJGP Open. 2022;Epub May 6.
Medication prescribing errors are common, particularly during medical training. This retrospective review of prescriptions from ten general practitioners in training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed) and suboptimal prescribing (35%).
Joseph AL, Monkman H, Kushniruk AW, et al. Stud Health Technol Inform. 2022;2022:535-539.
Patient portals allow patients and their caregivers to read clinical notes, view test results, and communicate with their provider, with the goal of improving patient safety. This scoping review found limited evidence of improved patient safety with the use of patient portals. Additionally, the authors found multiple naming conventions, such as patient portal, personal health record, and personal medical record.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;Epub Apr 27.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
Al-Khafaji J, Townshend RF, Townsend W, et al. BMJ Open. 2022;12:e058219.
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.
Ramani S, Halpern TA, Akerman M, et al. Am J Obstet Gynecol. 2022;226:556.e1-556.e9.
Cesarean delivery can lead to adverse outcomes and is commonly used as a measure of obstetrical quality; however, these measures do not account for preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. This article describes the development and testing of a new obstetrical quality measure that integrates cesarean delivery rates adjusted for preexisting high-risk maternal factors as well as maternal and neonatal morbidities. Among obstetricians in one large hospital, researchers found that this metric led to significantly different clinician rankings in terms of obstetrical quality (compared to rankings based on crude or adjusted cesarean delivery rates alone.) The authors suggest that this new metric can help identify opportunities for practice improvement among individual clinicians and institutions.
Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;Epub Apr 19.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
Giardina TD, Hunte H, Hill MA, et al. J Patient Saf. 2022;Epub Apr 27.
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.”
Bradford A, Shahid U, Schiff GD, et al. J Patient Saf. 2022;Epub Apr 21.
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.
Feng T-ting, Zhang X, Tan L-ling, et al. J Nurs Adm. 2022;52:160-166.
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.
Silva LT, Modesto ACF, Amaral RG, et al. Eur J Clin Pharmacol. 2022;78:435-466.
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.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.

National Academies of Sciences, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 21, 2022, 11:30 AM-6:30 PM (eastern).

The care of older adult patients can be complicated due to comorbidities and polypharmacy. This session will examine diagnostic challenges unique to the older adult population. The existing evidence base and research strategies for the future will be discussed.