Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 2153

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.

Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8(4):e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.
Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;Epub Jan 5.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.
St.Pierre M, Grawe P, Bergström J, et al. Safety Sci. 2021;147:105593.
The release of the Institute of Medicine (IOM)’s To Err is Human report in 1999 was a seminal moment in the patient safety movement. This bibliometric analysis found that the report has been mentioned in over 20,000 scientific publications since 2000, but that the themes of recent research do not necessarily align with the initial focus of the IOM report. For example, research on incident reporting and systems approaches to improving safety are underrepresented relative to their emphasis in the IOM report.

Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.
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.

Bryant A. UpToDate. September 13, 2021.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
Brush JE, Sherbino J, Norman GR. BMJ. 2022;Epub Jan 7.
Misdiagnosis of heart failure can lead to serious patient harm. This article reviews the cognitive psychology of diagnostic reasoning in cardiology. Strategies for educators, students, and researchers to reduce cardiovascular misdiagnosis are presented.

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.

Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21(1):139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17(8):e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.
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

An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions.

Institute for Healthcare Improvement. March 17-23, 2022, Boston, MA.
Organization executives influence the success of patient safety improvement. This onsite workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.