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.
Gillies D, Chicop D, O'Halloran P. Crisis. 2015;36:316-324.
This study used root cause analysis to identify underlying causes of suicide among mental health service clients. Researchers found that most patients had denied suicidal ideation and had missed follow-up in their mental health care. Their results underscore the challenge of preventing suicide in patients with mental illness.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.
Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-40.
Poor care coordination has been shown to be a risk factor for preventable errors in the ambulatory setting, and patients consistently voice concern about care coordination problems. This survey, which builds on prior Commonwealth Fund reports, found that care coordination was a major determinant of patient-reported medication errors in all seven countries studied. The study reinforces the role of health systems in ambulatory patient safety, and the need for improved communication between providers and better integration of health systems to reduce preventable errors for outpatients.
Allan J, Ball P, Alston M. Rural Remote Health. 2008;8:835.
Drawing from qualitative interviews with pharmacists and social workers, investigators determined that access to rural health services is affected by individual concerns about privacy and confidentiality, and by the reputation and value system of the health care worker.
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