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This editorial describes one clinician’s experience treating a patient during the early stages of the COVID-19 pandemic, and the impacts of “COVID blindness” and anchoring bias, which resulted in delayed sepsis treatment for this patient.

To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography.  To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.

Hand hygiene remains one of the most basic targets for enhancing patient safety. Poor hand hygiene compliance persists despite multiple global efforts, and a recent study showed handwashing rates are likely even lower when there is not a direct observer recording compliance. This prospective controlled trial in two medical intensive care units (ICUs) studied the effect of an electronic reminder system. An audible chime for each room entry and exit initially increased handwashing events in the test ICU, but this effect quickly declined, likely related to alert fatigue. In contrast, a combination of a chime and real-time computer monitor feedback of current hygiene compliance rates resulted in an increase that lasted throughout the study phase. Once the reminder system was turned off, compliance rates returned to the previous baseline. Overall hand hygiene compliance rates were quite low: recorded handwashing occurred in only about one-third of room entries or exits. A prior AHRQ WebM&M perspective reviewed innovations in promoting hand hygiene compliance.

Hand hygiene is critical to prevention of health care–associated infections. Despite intensive efforts, hand hygiene is not practiced universally in clinical settings. This systematic review sought to evaluate the effectiveness of patient-focused interventions to enhance adherence to hand hygiene practices. Researchers examined studies aimed at encouraging patients to remind health care providers to wash their hands. Because of the limited number and quality of current studies, researchers were unable to draw firm conclusions. Encouragement from health care providers seemed to be an important predictor for success in empowering patients to speak up about hand hygiene concerns. The authors recommend conducting more methodologically rigorous studies in order to determine the impact of patient-focused initiatives to promote hand hygiene. A recent AHRQ WebM&M perspective discussed strategies to enhance hand hygiene compliance.

This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.

This revision of the 2010 committee statement describes important characteristics for tracking systems and patient reminders to prevent missed or delayed diagnoses.

This comparison of different methods for promoting hand hygiene found that patient-centered reminders were effective at improving hand hygiene rates.

Discussing hospital-acquired conditions and strategies for prevention, this commentary recommends assigning a hospital-based clinician to assess safety at the individual patient level.

This article describes how missing patient information and disregarded reminders in electronic medical records can contribute to errors in care.

Efforts to prevent medication-related adverse events after hospital discharge have largely focused on medication reconciliation at the time of discharge. This study reports on the early experience with a medication reconciliation tool for use by primary care physicians after discharge. Although initial uptake was low, the study reports on many lessons learned through initial implementation.

Preventing overuse of potentially dangerous medications has continued to be a challenge for the safety movement, despite increasing use of technological solutions such as computerized order entry and clinical decision support. This study targeted prescribing for drugs classified as requiring a black box warning by implementing reminders within an ambulatory electronic medical record. Certain specific alerts, such as warning against prescribing drugs contraindicated in pregnancy or those with high potential for drug–drug interactions, were effective. However, overall prescribing of contraindicated medications did not decrease. Prior studies have also found limited benefit from prescribing reminders in ambulatory care, and a recent systematic review found that point-of-care clinician reminders, such as those used in this study, generally achieved only limited successes.

A multifaceted intervention resulted in increased voluntary reporting of safety incidents in two intensive care units.

Clinicians often must have patients discontinue taking inappropriate or potentially harmful medications, in order to minimize adverse effects or eliminate drug–drug interactions. This systematic review found several potentially effective strategies for withdrawing such prescriptions.

Tests pending after hospital discharge or following a clinic visit continue to challenge most health care systems. This study implemented a paper-based system to follow up abnormal mammograms and monitored provider responses to those reminders. Based on a report of abnormal mammograms generated by the radiology department, a practice administrator sent a letter to each provider with a copy of the report and a set of questions on behalf of their quality improvement committee. More than 90% of providers responded to the fail-safe reminders, 8% were unaware of the abnormal test, and there was no follow-up plan in place for 3% of cases. Less experienced providers were more likely to be unaware of abnormal mammograms and many lapses were noted in the context of care transitions. The authors conclude that their paper-based system is feasible and valuable but requires full engagement of providers in the process.