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Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
Domingo J, Galal G, Huang J. NEJM Catalyst. 2022;3.
Failure to follow up on abnormal diagnostic test results can cause delays in patients receiving appropriate care. This hospital used an artificial intelligence natural language processing system to identify radiology reports requiring follow-up. The system triggered automated notifications to the patient and ordering provider, and tracked follow-ups to completion. System development, deployment and next steps are detailed.
Rajan SS, Baldwin JL, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.
Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.
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.
Reeves JJ, Ayers JW, Longhurst CA. J Med Internet Res. 2021;23:e24785.
The COVID-19 pandemic has led to an extraordinary increase in the use of telehealth. This article discusses unintended consequences of telehealth and outlines guidance to assist health care providers in determining the appropriateness of a telehealth visit.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.
Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18:40-45.
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.   
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.

Brodwin E. Stat News. April 14, 2020.

Patients with cancer and other chronic disorder treatment needs have been negatively affected by the restructuring of services to reduce the spread of the coronavirus. This story discusses company strategies to prepare to virtually support patients with a range of conditions. The author shares communication and support tactics to keep patients safe until they can get their appointments.
Kattel S, Manning DM, Erwin PJ, et al. J Patient Saf. 2020;16.
Prior research has found poor communication between hospital-based and primary care physicians and has suggested that this may contribute to medical errors. This systematic review included 19 studies assessing the transfer of information at hospital discharge between hospital-based and primary care providers (PCPs), or evaluating interventions aimed at improving the timeliness and quality of discharge information. The review found that timely communication of discharge summaries was low, with 55% (median) transferred to PCPs within 48 hours and 85% (median) within 4-weeks; 8.5% of discharge summaries were never transferred. Discharge summaries nearly always contained patient demographics, admission/discharge dates and primary diagnoses, but less frequently included pending test results, diagnostic tests performed and discharge medications.
Blease CR, Fernandez L, Bell SK, et al. BMJ Qual Saf. 2020;29:864–868.
Providing patients – particularly elderly, less educated, non-white, and non-English speaking patients – with access to their medical records via ‘open notes’ can improve engagement in care; however, these demographic groups are also less likely to take advantage of these e-tools. The authors summarize the preliminary evidence and propose steps to increasing use of open note portals among disadvantaged patients.
Lacson R, Healey MJ, Cochon LR, et al. J Am Coll Radiol. 2020;17:765-772.
Radiological exams are often ordered but go unscheduled, which can delay diagnoses and lead to other medical errors. In this retrospective study at one academic institution, the clinical necessity of 700 unscheduled radiologic examination orders (100 from each of seven different radiographic modalities) was examined. Study results indicate that, except for CT, obstetric ultrasound and fluoroscopy radiologic tests, the majority of unscheduled orders are clinically necessary and that 7% of all radiologic examination orders remain unscheduled a month or more after the order was placed.
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.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Mays JA, Mathias PC. J Am Med Inform Assoc. 2019;26:269-272.
Point-of-care test results are often manually transcribed into the electronic health record, which introduces risks of manual transcription errors. The authors of this study took advantage of a redundant workflow in which point-of-care blood glucose results were uploaded and also manually entered by staff. They estimate that 5 in 1000 manually entered results contain clinically significant transcription errors and call for interfacing point-to-care instruments as a patient safety strategy.
Khoong EC, Cherian R, Rivadeneira NA, et al. Health Aff (Millwood). 2018;37:1760-1769.
California's Medicaid pay-for-performance program requires safety-net health care systems to report and improve upon diverse ambulatory safety measures. Researchers found that participating safety-net hospitals struggled to report accurate data. Systems had more success improving metrics that placed patients at risk of life-threatening harm when compared to metrics that required longer term follow-up or patient engagement.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.