Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.

Because patients discharged from the intensive care unit (ICU) are at increased risk of readmission and post-ICU adverse events, some hospitals have opened post-ICU clinics. This article describes safety threats identified by post-ICU clinic staff. Medication errors and inadequate medical follow-up made up nearly half of identified safety threats. More than two-thirds were preventable or ameliorable.

Use of abbreviations in electronic health records increases risk of misunderstandings, particularly between providers of different specialties. In this study, junior doctors and general practitioners were asked about their understanding of common, uncommon, and rare abbreviations used in hospital discharge notes. No abbreviation was interpreted in the same way by all respondents, and nearly all respondents left at least one abbreviation blank or responded that they didn't know.

Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   

Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.

Transitions of care can increase risks for patient safety events. This systematic review examined the effectiveness of interventions aimed to increase patient safety during transitions of care between the hospital and home. The authors identified several interventions from previously published studies which increased patient safety and/or patient satisfaction and identified factors that contribute to effective transitions of care (i.e., nurse follow-up, pre-discharge patient education, and contact with local healthcare services).

Women often experience misdiagnosis and diagnostic delays due to process failures and implicit bias. This multicenter cohort study including 190 patients found that women were more likely to experience delays in diagnosis and misdiagnosis of inflammatory bowel disease, as compared to men. Researchers found that these inequities in misdiagnosis occurred across all healthcare settings (emergency department, primary care, gastroenterology, and hospital admission).

Women’s pain has been underestimated compared to men’s pain, and treatments differ based on gender. This commentary revisits the findings from the 2001 article The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. The authors state progress has been made in the past 20 years, but disparities still exist. Additional research is needed, particularly into chronic pain conditions that are more common in women.

Inappropriate referrals and unnecessary hospital admissions are ongoing patient safety problems. This cohort study set in Norway examined the impact of emergency physician referral thresholds from out-of-hours services on patient outcomes.  

Premature diagnostic closure, also called anchoring bias, relies on initial diagnostic impression without continuing to explore differential diagnoses. This commentary proposes a cognitive forcing strategy of “endpoint diagnosis,” or continuing to ask “why” until additional diagnostic evaluations have been exhausted. The authors describe four common contexts when endpoint diagnoses are not pursued or reached.

Diagnostic errors continue to be a source of patient harm. This retrospective study identified patient- and organizational-level factors contributing to misdiagnosis of chronic wounds in primary care. Less than half of patients referred from primary care to specialist wound care teams had the correct diagnosis. Notably, 36% of patients who presented to primary care had signs of infection, however 61% received antibiotics, raising concerns of antibiotic overuse.

Delayed referrals from primary care providers to specialty care can lead to delayed diagnoses and patient harm. This retrospective analysis examined differences in timely versus delayed referrals for urgent skin cancer evaluations at one institution. Among 320 referrals occurring in 2018, 38% of evaluations occurred 31 days or more after the referral and nearly 11% of referrals were never completed. Delayed referrals were more common among patients who did not speak English and racial/ethnic minorities.

The CancelRx tool is designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. However, interoperability issues can limit the tool’s usefulness and result in inadvertent dispensing of discontinued medications. This evaluation of discontinued medications at one health systems over a one-month period found that only one-third to one-half of discontinued medications were e-prescribed using the same EHR system and would result in a CancelRx message to the pharmacy; the remainder of discontinued medications were patient-reported or reconciled from outside sources.

Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.

Electronic health records (EHR) systems frequently interact with EHRs in other organizations, between clinical settings (e.g., in-patient and out-patient), or with devices (e.g., smart pumps). In this review, 12 studies were identified that examined the effect of EHR interoperability on patient safety. While EHR interoperability was shown to improve patient safety, outcome measure heterogeneity limits measuring true effects.

Metacognition (e.g., when one reflects on one’s own decision and decision making) is an approach to reducing diagnostic errors. Using data from the Melanoma Pathology Study (M-PATH) and Breast Pathology Study (B-PATH), researchers assed pathologists’ metacognition by examining their diagnostic accuracy and self-confidence. Results showed pathologists with increased metacognition sensitivity were more likely to request a second opinion for incorrect diagnosis than they were for a correct diagnosis.

Failure to communicate blood test results to patients may result in delayed diagnosis or treatment. In this study, UK primary care patients and general practitioners (GPs) were asked about their experiences with the communication of blood test results. Patients and GPs both expected the other to follow up on results and had conflicting experiences with the method of communication (e.g., phone call, text message).

Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.