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The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.

The instrument consists of a series of questions that address five aspects of the diagnostic process: (1) the patient-provider encounter (history, physical examination, ordering tests/referrals based on assessment); (2) performance and interpretation of diagnostic tests; (3) follow-up and tracking of diagnostic information over time; (4) subspecialty and referral-specific factors; and (5) patient-related factors.1 To answer the questions, the evaluator collects data from comprehensive electronic health records including information on a patient’s medical history, examination information, diagnostic test interpretation, and follow-up testing and diagnostic assessment. If the assessment indicates there was a likely diagnostic error (defined as a missed opportunity in diagnosis), users have the option to complete an additional process breakdown assessment as a guide designed to help identify factors contributing to the potential missed opportunity.

The original tool, the Safer Dx Instrument, was validated in a primary care setting, and results were published in 2016. In this study, the instrument yielded overall accuracy of 84%.2 A study published in 2017 on use of the tool in a pediatric intensive care unit found the tool had inter-rater agreement of 93.6% (k, 0.72).3 The project team made minor revisions to the original tool to address feedback from the pilot studies, as well as from several national experts. Since the release of the revised iteration of the tool (i.e., the Revised Safer Dx Instrument), use of condition-specific adaptations of the tool (e.g., Safer Stroke Dx) have found it to yield accurate results.4,5

For the best results, the project team suggests having multiple reviewers complete the assessment and discuss findings. Additionally, sites that wish to implement the tool may benefit from an existing safety environment that is supportive, with elements such as a patient safety culture, existing safety programs, and adequate staffing resources to implement the tool, including a multidisciplinary team with a dedicated safety analyst.

Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22(12):2553-2558.e1.
Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.
Höcherl A, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18(1):e85-e91.
Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.
Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12(1):37-46.
Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.
This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.1 Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice the rate of the general population.1,2

The STORM decision support system uses data extracted from VHA electronic medical records and predictive analytics to facilitate the identification of patients at high risk of experiencing overdose and suicide events. The STORM decision support system can also review risk factors for patients who are being considered for prescription opioid therapy. STORM prioritizes patients for monitoring and intervention according to their modeled risk and aids clinicians by displaying a patient’s risk factors and associated evidence-based risk mitigation interventions. Note that the target population does not include patients with OUD in medication-assisted treatment (MAT).

Many patients with OUD and/or in prescription opioid therapy have complex medical and psychosocial needs (e.g., painful conditions, mental health challenges), resulting in interactions with multiple care providers. To address the complexity of a patient’s case, STORM aims to provide a holistic intervention that includes multiple care providers and accounts for multiple parts of the patient’s history and medical profile.3 Under the STORM-based targeted prevention program, an interdisciplinary team of clinicians, including those with expertise in pain and behavioral health, conduct case reviews for patients identified to be at the highest risk of overdose and/or suicide and implement treatment changes or share recommendations with the patients‘ providers.

The VHA completed a three-year randomized program evaluation of the implementation of the national STORM-based targeted prevention program. Preliminary results indicate that mandating that very high-risk patients receive an interdisciplinary review was associated with a decrease in all-cause mortality among identified patients in the 127 days after identification by the decision support system.4

The STORM decision support system and targeted prevention program were developed and implemented in the context of relatively high rates of opioid prescribing to veterans and overall rising opioid-involved overdose mortality in the U.S. population. In the last 10 years, overdose deaths have more than doubled in the United States.5 As one response to the problem, the 2016 Comprehensive Addiction and Recovery Act requires the VHA to improve opioid therapy strategies and to ensure responsible prescribing practices. STORM is one of several VHA overdose prevention initiatives that include the distribution of naloxone, efforts to reduce opioid prescribing, and introduction of pain management clinical review and support teams.5

Kemp T, Butler‐Henderson K, Allen P, et al. Health Info Libr J. 2021;38(4):248-258.
This review focused on the impact of the Health Information Management (HIM) profession on patient safety as it relates to health information documentation. Key themes identified were data quality, information governance, corporate governance, skills, and knowledge required for HIM professionals.
Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48(2):71-80.
The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11(11):CD009985.
Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.
Bickmore TW, Olafsson S, O'Leary TK. J Med Internet Res. 2021;23(11):e30704.
Patients and families increasingly access mobile apps, conversational assistants, and the internet to find information about health conditions or medications. In a follow up to an earlier study, researchers evaluated two approaches to determine the likelihood that patients would act upon the information received from conversational assistants.

Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

McMaster Faculty of Health Sciences Office of Continuing Professional Development, and McMaster Education Research, Innovation, and Theory. February 16, 2022 (10:00 AM –4:00 PM (eastern).

Clinical reasoning is vulnerable to a variety of cognitive and environmental conditions that can affect its accuracy. This virtual conference will explore how artificial intelligence, system influences, and social integrity impact clinical reasoning.
Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2021;Epub Sep 12.
Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.
Blease CR, Kharko A, Hägglund M, et al. PLoS ONE. 2021;16(10):e0258056.
Allowing patients to access their own ambulatory clinical health record has benefits such as identification of errors and increased trust. This study focused on risks and benefits of patient access to mental health care records. Experts suggested the benefits would be similar to those seen in primary care, such as increased patient engagement, with the potential additional benefit of reduced stigmatization.
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4(4):ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33(4):mzab142.
Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43(5):1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.