Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.
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).
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.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Pandya C, Clarke T, Scarsella E, et al. J Oncol Pract. 2019;15:e480-e489.
Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.
Herlihy M, Harcourt K, Fossa A, et al. Obstet Gynecol. 2019;134:128-137.
Prior research has shown that when patients have access to clinicians' notes, they may identify relevant safety concerns. In this study, 9550 obstetrics and gynecology patients were provided with access to their outpatient visit documentation. Almost 70% of eligible patients read one or more notes during the study period, but only 3.2% shared feedback through 232 electronic reports. Of patients who provided feedback, 27% identified errors in the documentation; provider reviewers determined that 75% of these could impact care.
Transferred to the emergency department from the transfusion center after becoming unresponsive and hypotensive, an elderly man with signs of sepsis is given incomplete and delayed antimicrobial coverage due to a history of penicillin allergy. Neither gram-negative nor anaerobic coverage were provided until several hours later, and the patient developed septic shock.
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
Driver BE, Scharber SK, Fagerstrom ET, et al. J Emerg Med. 2019;56:109-113.
This pre–post study examined the effect of an electronic health record alert that required physicians to respond "yes" or "no" regarding whether tests were pending at the time of discharge from the emergency department. Investigators found that physician responses were often inaccurate, and the proportion of discharged patients with tests pending increased following the intervention, contrary to intentions.
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.
Barbieri AL, Fadare O, Fan L, et al. J Pathol Inform. 2018;9:8.
This secondary data analysis of electronic health record (EHR) messages addressed to pathologists uncovered gaps in clinician-to-clinician communication. A range of clinicians used the EHR to ask clinical questions of pathologists, and pathologists largely did not use the EHR message inbox. The authors suggest that design and implementation of electronic tools should anticipate and address these potential safety problems.
Gilliland N, Catherwood N, Chen S, et al. BMJ Open Qual. 2018;7:e000170.
Incomplete communication regarding patient information can diminish the safety of care delivery. This commentary describes how a quality improvement project applied plan–do–study–act cycles to enhance collection of patient data. Researchers developed, tested, and refined a ward round template in a United Kingdom urology service and increased compliance in the recording of patient care measures.
Zuccotti G, Samal L, Maloney FL, et al. Ann Intern Med. 2018;168:820-821.
Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.
Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
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.
Bastawrous S, Carney B. J Digit Imaging. 2017;30:309-313.
Inadequate test result management is known to contribute to missed and delayed diagnosis. This Veterans Affairs study found that 0.17% of radiologic studies were not evaluated by radiologists. The study team identified several technical and process problems that contributed to these unread studies. They were able to address the issues to ensure all studies were read.
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