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Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.
Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits.

Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;Epub Feb 28.
Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.
Giardina TD, Choi DT, Upadhyay DK, et al. J Am Med Inform Assoc. 2022;29:1091-1100.
Most patients can now access their provider visit notes via online portals and many have reported mistakes such as diagnostic errors or missed allergies. This study asked patients who may be “at-risk” for diagnostic error about perceived concerns in their visit notes. Patients were more likely to report having concerns if they did not trust their provider and did not have a good feeling about the visit. Soliciting patient concerns may be one way to improve transparency regarding diagnostic errors and trust in providers.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;Epub Mar 4.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
Nehls N, Yap TS, Salant T, et al. BMJ Open Qual. 2021;10:e001603.
Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.
Zomerlei T, Carraher A, Chao A, et al. J Patient Saf Risk Manage. 2021;26:221-224.
Failure to communicate abnormal test results to patients can lead to significant health complications and medical malpractice claims. This study aimed to increase patient engagement in asking their provider about previously obtained diagnostic test results. Reminders to follow up with their provider about test results were sent to the patient via the after-visit summary and patient portal. Patients receiving reminders were up to 20 times more likely to ask their providers about their test results, compared to patients who did not receive reminders.
Singh H, Connor DM, Dhaliwal G. BMJ. 2022;376:e068044.
System and clinician behaviors affect the reliability of the diagnostic process. This article shares five strategies to enhance individual clinician diagnostic practices which include seeking feedback, building learning into daily work, considering bias, enabling critical thinking, and teaming.

A 65-year-old woman with a history of 50 pack-years of cigarette smoking presented to her primary care physician (PCP), concerned about lower left back pain; she was advised to apply ice and take ibuprofen. She returned to her PCP a few months later reporting persistent pain. A lumbar spine radiograph showed mild degenerative disc disease and the patient was prescribed hydrocodone/acetaminophen in addition to ibuprofen. In the following months, she was seen by video twice for progressive, more severe pain that limited her ability to walk.

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

Berntsson K, Eliasson M, Beckman L. BMC Nurs. 2022;21:24.
Safe and accurate telephone triage is of critical importance, particularly during the COVID-19 pandemic. This Swedish study evaluated district nurses’ experiences and perceptions of patient safety at a national nurse advice triage call center. Interviews with nurses resulted in an overall theme of “being able to make the right decision” based on the categories of “communication” and “assessment.”
Bell SK, Dong J, Ngo L, et al. BMJ Qual Saf. 2022;Epub Feb 4.
Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2022;146:886-893.
A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.
Centola D, Guilbeault D, Sarkar U, et al. Nature Commun. 2021;12:6585.
Race and gender bias in healthcare remains a public health problem. Study participants were assigned to a control (i.e., independent reflection) or intervention (i.e., “egalitarian” information exchange network) group and asked to provide diagnostic and treatment recommendations for standardized patients (a white man or a black woman). Participants in the intervention group were more likely to recommend appropriate care and showed no bias in final recommendations. The authors note that these findings indicate that clinician network interventions might be useful in healthcare settings to reduce disparities in patient treatment.
Berwick DM. JAMA. 2021;326:2127-2128.
Efforts to improve diagnosis recognize the value in patient-centered care. This commentary outlines how a diagnostician can enfold patient centeredness into their practice, which includes the seeking of knowledge and moderation of actions taken to arrive at a diagnosis. This piece is part of a series on diagnostic excellence.
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104:2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.