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This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.
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.   
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

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.
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.
Dinsdale E, Hannigan A, O'Connor R, et al. Fam Pract. 2019.
Clear communication between primary care physicians and the providers to whom they refer patients has important implications for achieving accurate diagnosis and appropriate treatment plans for patients. In this observational study, researchers included 6603 patients from 68 general medical practices in Ireland, randomly selecting 100 patients from each practice and excluding patients without complete records. They analyzed referral documentation and responses received from subspecialists as well as discharge summaries from hospitalizations over a 2-year period, compared with established national standards. Although 82% of referral letters included current medications, only 30% of response letters and discharge summaries contained medication changes and 33% had medication lists. The authors conclude that significant communication gaps exist between primary and secondary care and that further research is needed to understand how to address them. A past PSNet perspective discussed challenges associated with care transitions.
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.
Given BA. Semin Oncol Nurs. 2019;35:374-379.
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.
Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so).
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.
Butcher L.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
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.