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US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie Health. We spoke with her about the emergence of application-based tools used for healthcare and the patient safety issues surrounding the use of such tools.

117th Congress 2d Session. June 21, 2022.

Strengthening diagnostic error research and training can lead to sustained diagnostic improvement. Expanding upon legislation introduced in 2020, the “Improving Diagnosis in Medicine Act of 2022” would establish research centers of diagnostic excellence, an interagency council on improving diagnosis in healthcare, and fellowship and training grants in diagnostic safety, as well as convene an expert panel on diagnostic error measurement and data collection and prioritize stakeholder engagement across all activities.

Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022.  ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.

Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

Hostetter M, Klein S. New York, NY: Commonwealth Fund;  October 18, 2021

Structural racism affects the safety and equity of care delivery. This report summarizes organizational efforts to reduce the impact of systemic racism on patient care, hiring practices, and policy implementation to ensure transparent, equitable and patient-centered care is reliably available to all.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

Renault M. Stat. July 28, 2021.

Care and safety concerns for patients, families, and clinicians continue to be challenged by COVID-19. This article discusses the unintended consequences of isolation practices during the pandemic as a contributor to patient harm due to resultant family support barriers and loneliness they caused.