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Zimolzak AJ, Shahid U, Giardina TD, et al. J Gen Intern Med. 2022;37:137-144.
Inadequate follow-up of diagnostic testing can lead to missed or delayed diagnoses. Based on interviews with healthcare workers at Veterans Affairs (VA) facilities across the United States, this qualitative study identified factors contributing to lack of timely follow-up of abnormal test results. The most commonly cited factors included trainee/resident involvement, absence of a process to address  incidental findings on imaging, lack of standardized electronic health records (EHR) and related tracking systems, and lack of updated patient and provider contact information. The authors summarize participant recommendations to reduce missed test results.
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Dadlez NM, Adelman J, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.

Formerly known as the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), the University of Arkansas for Medical Sciences (UAMS) High-Risk Pregnancy Program links clinicians and patients across the state with UAMS, where the vast majority of the state's high-risk pregnancy services, maternal-fetal medicine specialists, and prenatal genetic counselors are located.

A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Artis KA, Bordley J, Mohan V, et al. Crit Care Med. 2019;47:403-409.
Reporting complete patient information during clinical rounds is important for achieving an accurate diagnosis and informing clinical management. Prior research has shown that data is sometimes omitted or inaccurately communicated on rounds. This observational study compared patient data shared by trainees and medical students on ICU rounds to that contained within the electronic health record. Researchers analyzed photocopies of trainee and student notes as well as audio recordings of their oral presentations. For the 157 patient presentations included in the study, they found all contained data omissions and that other team members on rounds supplemented a minimal amount of data missing from student and trainee presentations. The authors recommend additional oversight and education of trainees with regard to data presented on rounds.
Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed.
Whitehead NS, Williams L, Meleth S, et al. J Hosp Med. 2018.
Test results pending at the time of hospital discharge can lead to a delay in diagnosis and represent a significant patient safety risk. This systematic review found that certain electronic and educational interventions may improve documentation and awareness of pending test results. The authors suggest that further research is needed to understand how these interventions affect processes and outcomes.
Farmer B. Emerg Med (N Y). 2016;48.
Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.
Walia J, Qayumi Z, Khawar N, et al. Acad Pediatr. 2016;16:519-23.
The I-PASS standardized handoff protocol is considered the gold standard for inpatient handoffs, having been shown to reduce adverse events among hospitalized patients. In this study, implementation of I-PASS within an electronic medical record resulted in an improvement in handoff quality among pediatric residents. A recent PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Pell JM, Mancuso M, Limon S, et al. JAMA Intern Med. 2015;175:856-858.
In this study, allowing hospitalized patients to access their own medical records as a patient engagement strategy did not increase clinician workload or patient worry, but patients did not identify errors on their medication list or better understand discharge. Although enabling patient access to records in real-time did not have adverse effects, it did not appreciably improve patient safety in this modest sample.
Nabors C, Patel D, Khera S, et al. J Patient Saf. 2015;11:36-41.
Handoffs in the inpatient setting represent an ongoing challenge for patient safety. This intervention involving event reports for key overnight incidents automatically emailed to the daytime team reduced handoff duration, and team members suggested that this improved the quality of handoffs. This workflow-informed and technology-enabled approach reflects the growing influence of systems thinking in health care safety.
Stephenson LS, Gorsuch A, Hersh WR, et al. BMC Med Educ. 2014;14:224.
In this educational study, medical residents missed patient safety issues in a simulated review of the electronic health record. Repeated simulations resulted in improved but suboptimal performance. These findings support the widespread concern that problems with electronic health record usability lead to patient safety events.
American Hospital Association; AHA.
Hospitals and health systems face challenges in implementing electronic health records that can affect safety. This webinar introduced the SAFER guides, which highlight strategies to improve safety related to electronic health record use, and educate participants about ways to implement these guides in their organizations. The session featured Hardeep Singh and Dean F. Sittig as speakers.
Joffe E, Turley JP, Hwang KO, et al. BMJ Qual Saf. 2014;23:398-405.
Clinicians must routinely triage and manage clinical issues over the telephone, but prior research has shown that this process is often error-prone. This simulation study of telephone triage in hospitalized patients found bidirectional problems with communication, as nurses frequently failed to provide crucial information and physicians did not take appropriate action even when properly informed.
Wohlauer M, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-7.
This study implemented a computerized rounding and sign-out tool, which supported greater efficiency for residents in their pre-rounding activities. The authors suggest that such tools can promote safe care transitions and promote compliance with resident work-hour restrictions.
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.