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Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96(9):1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Jagneaux T, Caffery TS, Musso MW, et al. J Patient Saf. 2021;17(6):425-429.
Emergency and internal medicine residents attended a course on central venous access that included lectures, videos, and simulation using a task trainer. Comparison of pre- and post-training evaluation demonstrated significant improvement in knowledge, confidence, and procedural skills.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The current data submission window launched on September 1 and runs through October 20, 2021.
Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4(7):e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Catalanotti JS, O’Connor AB, Kisielewski M, et al. J Gen Intern Med. 2021;Epub Jan 30.
Overnight coverage creates opportunities for increasing resident autonomy but can carry risks for patient safety.  This study found that the presence of overnight hospitalists was associated with fewer resident barriers to contacting supervising physicians overnight but that other barriers during overnight coverage – such as technological barriers and organizational culture – influence residents seeking help from supervising physicians.
Konopasky A, Artino AR, Battista A, et al. Diagnosis (Berl). 2020;79(3):257-264.
This study explored the influence of contextual factors (i.e., factors beyond the case content potentially influencing reasoning) on context specificity and clinical reasoning. Internal medicine residents and attending physicians viewed outpatient clinic videos involving unstable angina and diabetes mellitus – one video with distracting contextual factors and one without. The results provide insight into factors influencing diagnostic reasoning during outpatient visits for common medical conditions.
Reaume M, Farishta M, Costello JA, et al. Postgrad Med J. 2020;97(1143):55-58.
Point-of-care ultrasounds (POCUS) are considered a powerful tool to enhance patient safety through expedited diagnosis, but also present safety threats. There is a concern that POCUS use may contribute to diagnostic error lawsuits. The authors reviewed lawsuits involving the diagnostic use of POCUS in internal medicine, pediatrics, family medicine, and critical care and did not find any cases of physicians in these specialties being subject to adverse legal action for the diagnostic use of POCUS.   
Sweet W, Snyder D, Raymond M. J Healthc Risk Manage. 2020.
This article describes one health system’s experience implementing an infection prevention program into risk management in an outpatient setting. Over a two-year period post-implementation, the system identified and corrected high-risk practices, increased compliance to device guidance, increased efficiency with the use of central sterile processing departments, and developed a staff competency training structure.

Mosley T. COVID-19 leads to increased need for dialysis machines. Here & Now. Boston Public Radio. April 27, 2020.

Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for treating patients with COVID-19 who also experience kidney failure and a lack of dialysis machines and the professionals to run them.
Gartland RM, Myers LC, Iorgulescu JB, et al. J Patient Saf. 2020;Epub Mar 23.
This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.
Matulis JC, Kok SN, Dankbar EC, et al. Diagnosis. 2020.
A brief survey of two internal medicine practices explored clinician perceptions of individual- and systems-level factors contributing to diagnostic errors. The most commonly reported individual-level factors contributing to diagnostic error was atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). Common systems-level contributors identified were cognitive burden associated with the electronic health record system (68%), inadequate time (64%) and lack of collaboration (40%).
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge. Healthcare Safety Investigation Branch. Farnborough, UK: 2019.
Design flaws and improper use of technologies that transfer medication and prescription information between provider environments is a known threat to patient safety. This report analyzes an anticoagulant overdose incident and found that information technology missteps contributed to the error.
Ganguli I, Simpkin AL, Lupo C, et al. JAMA network open. 2019;2:e1913325.
Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.
Szymusiak J, Walk TJ, Benson M, et al. Ped Qual Saf. 2019;4(3):e167.
Encouraging adverse event reporting among health care providers, including medical trainees, is critical to improving patient safety. This qualitative study convened focus groups to elucidate what factors support event reporting among medical residents. Residents were more likely to use reporting tools when they had received training about the process, and identified specific interventions, to encourage reporting, such as role modeling by faculty.
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear.
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures.
Kittleson M. JAMA. 2019;322(10):984.
Medical mistakes are a source of anxiety for both patients and clinicians. This poem articulates a physician's perspective regarding the psychological impact of uncertainty and errors in daily practice.
Best JA, Kim S. Journal of continuing education in nursing. 2019;50:355-361.
A key aspect of a robust safety culture is that all team members feel psychologically safe in difficult situations. This commentary describes the development and use of a speaking-up curriculum that focuses on communication skills, cultural expectations, cognitive restructuring techniques, and resilience strategies. The program successfully increased motivation and comfort of participants in sharing concerns in various clinical situations.
Kittleson M. JAMA. 2019;322:984.
Medical mistakes are a source of anxiety for both patients and clinicians. This poem articulates a physician's perspective regarding the psychological impact of uncertainty and errors in daily practice.