What’s New in the Patient Safety World

September 2018

ECRI Institute Partnership: Closing the Loop



One of our most frequent topics has been communication errors that cause diagnostic errors and delays that may lead to disastrous patient outcomes (see list of columns at the end of today’s column). Recently, there have been several initiatives or studies that have expounded upon this issue.


ECRI Institute partnered with multiple organizations and convened an expert advisory panel to address the issues of errors or delays in diagnosis related to failure to follow up and errors related to changes or discontinuation of medications (ECRI Institute 2018). That Partnership for Health IT Patient Safety identified three key safe practice recommendations:


We hope you’ll access the ECRI Partnership toolkit which also contains an excellent slide presentation. The report and toolkit are very valuable resources that every healthcare organization can benefit from.


Meanwhile, our neighbors to the north have launched a campaign Greg’s Wings, highlighted by the film Falling Through the Cracks: Greg's Story. This is a powerful story of how failures in communication (“no news is good news”) led to diagnostic and therapeutic delays and ultimately the death of a young man. You’ve heard us so many times use the phrase “stories, not statistics” to drive buy-in from healthcare workers in a variety of patient safety issues. This film provides such a story.


One of the salient features in Greg’s Story is faxed referrals to specialists being lost and ignored. We highlighted the surprising continued role faxes play in healthcare and the problems associated with them in our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am”. An editorial in the Canadian press (Picard 2018) notes that, just as in the US, Canadian physicians still rely primarily on fax for communication with other physicians, despite the fact most have electronic medical record systems.


And failures in communication about diagnoses also happen when patients are transferred from one hospital to another. A recent study from University of Minnesota researchers (Usher  2018) looked at adult patients transferred between 473 acute care hospitals from 5 states from 2011 to 2013. The researchers found that discordance in diagnoses occurred in 85.5% of all patients. 73% of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Moreover, diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11).


But when both involved hospitals shared data via health information exchange (HIE) there was a reduced diagnostic discordance index (3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).


All these endeavors highlight the need for better communication on multiple levels in the healthcare continuum to reduce diagnostic errors and delays that may lead to adverse patient outcomes.



See also our other columns on communicating significant results:



Some of our prior columns on diagnostic error:








ECRI Institute. ECRI Institute's Partnership for Health IT Patient Safety Releases New Recommendations to Avoid Testing and Medication Mix-ups. Publicly available report offers important tools and guidance for all healthcare systems. ECRI Institute 2018; Press release July 26, 2018





Partnership for Health IT Patient Safety. Health IT Safe Practices for Closing the Loop. Mitigating Delayed, Missed, and Incorrect Diagnoses Related to Diagnostic Testing and Medication Changes Using Health IT. ECRI Institute 2018




Greg’s Wings




Film: Falling Through the Cracks: Greg’s Story




Picard A. Why are fax machines still the norm in 21st-century health care? The Globe and Mail (Toronto, Ontario) 2018; June 11, 2018




Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. Journal of General Internal Medicine 2018; 33(9): 1447-1453






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