Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).
Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-12.
Handovers, or handoffs, in patient care are a continued and problematic safety concern that were further elevated by The Joint Commission into a National Patient Safety Goal. Despite guidelines and past efforts to standardize the process with computerized tools, there are remaining opportunities for improvement. This study adopted a handover assessment instrument in the intensive care setting to evaluate the degree of information corruption in handover exchanges. Investigators discovered variances in information retained during a handover compared with actual facts from the medical record, and noted the potential for these variations to contribute to errors in care. The authors share their tool and advocate its use as a screening method to identify areas for improvement in the quality of handovers. A past AHRQ WebM&M case commentary discussed a fumbled handoff resulting from poor communication and lack of standardization in the process.
Gordon JRS, Wahls T, Carlos RC, et al. Ann Intern Med. 2009;151:21-7, W5.
This study discovered that more than half of newly identified aortic dilations on computed tomography scans were not documented by clinicians in subsequent encounters. The authors advocate for improved systems to follow up on abnormal test results.
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