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.
Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.
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.
Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882.
Physicians commonly use diagnostic algorithms and practice guidelines to individualize risk assessment and guide clinical decisions. The authors discuss the possible dangers of using race-adjusted algorithms due to their potential to lead to diagnostic errors and delays in care.
Kutikov A, Weinberg DS, Edelman MJ, et al. Ann Intern Med. 2020;172:756-758.
Oncology patients, as with other patients with chronic health care needs, face numerous challenges during the COVID-19 pandemic. The authors discuss the need to balance delays in cancer diagnosis or treatment against the harm of COVID-19 exposure, how to mitigate the risk for significant care disruptions associated with social distancing and managing the allocation of limited healthcare resources during this unprecedented pandemic.
Cancer patients often rely on family members or paid caregivers to assist with care maintenance at home, such as taking medications and mobility support. This review highlights common safety gaps in home cancer care. The authors suggest that nurses can help assess caregiver knowledge and provide education to address safety issues.
Dodge LE, Nippita S, Hacker MR, et al. J Healthc Risk Manag. 2019;38:44-54.
This pre–post study examined the implementation of AHRQ's TeamSTEPPS training program. Investigators found that the intervention had positive effects on staff ratings of teamwork and patient satisfaction, and these improvements persisted for one year.
Schwarz CM, Hoffmann M, Schwarz P, et al. BMC Health Serv Res. 2019;19:158.
Care transitions represent a vulnerable time for patients, especially at the time of hospital discharge. In this systematic review, researchers identified several factors related to discharge summaries that may adversely impact the safety of discharged patients, including delays in sending discharge summaries to outpatient providers as well as missing or low-quality information.
Cheong V-L, Tomlinson J, Khan S, Petty D. Prescriber. 2019;30:29-34.
Geriatric patients are particularly vulnerable to medication-related harm. This article summarizes types of incidents and contributing factors to adverse drug events in older patients after hospital discharge. The authors recommend strategies to reduce medication-related harm, including discharge communication improvements, primary care collaboration, and postdischarge patient education.
Molloy MA, Cary MP, Brennan-Cook J, et al. Home Healthc Now. 2018;36:225-231.
Patient utilization of home care is expected to increase with advances in medical care and health technologies. This commentary presents simulation as a promising tool to develop and assess home care staff skills to improve transitions from acute care to home health care.
Teamwork is an important element of safe care delivery. This review explores the evidence on the role of teams in ambulatory care, innovations in primary care teamwork models, and barriers to success. The authors offer recommendations to encourage team development in primary care, including defining team competencies, providing team training opportunities specific to ambulatory care, and adjusting care payment mechanisms.
Darrah NJ, O'Connor NR. J Pain Symptom Manage. 2016;51:959-962.e2.
Hospice providers often lack access to patient records, which can hinder patient transitions in this setting. This project report outlines an effort to develop curriculum associated with hospital-to-hospice handoffs to enhance transition practices and communication needs unique to palliative care.
Vaughan L, McAlister G, Bell D. Clin Med (Lond). 2011;11:322-326.
This survey of physicians about the UK equivalent of the "July effect"—a tradition of nearly 50,000 new doctors starting on the first Wednesday in August—found a high degree of concern for patient care, safety, and training. The authors conclude that there is a need for structural changes.
Boling PA. Clin Geriatr Med. 2009;25:135-48, viii.
This article reviews the literature on transitions of care, discusses interventions, and suggests that transitional care processes supported by effective home care programs can reduce rehospitalization.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child.
Taylor CR, Hepworth JT, Buerhaus PI, et al. Qual Saf Health Care. 2007;16:244-7.
A crew resource management teamwork training intervention was implemented at an urban primary care clinic, with the goal of improving care for diabetes patients. The effort resulted in short-term improvements in adherence to evidence-based care processes for diabetes.
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