Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is [...]

Background: Diagnostic errors (DE), defined as missed opportunities to make a correct or timely diagnosis based on the available evidence, are a critical but understudied cause of patient harm. While previous efforts have focused on examining the incidence and factors contributing to DEs in ambulatory and emergency room settings, fewer studies have examined incidence of [...]

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days), but little is known about their frequency and characteristics. We performed structured chart review of all medical patients readmitted within 7 days of discharge from a single academic medical center to describe the prevalence of [...]

Background: Diagnostic errors (DEs) represent ongoing threats to patient safety in the hospital. Little is known about the factors present on admission that can predict DE during the hospital encounter. Such knowledge is essential for prospective identification of hospitalized patients at risk for DE who can be targeted for early intervention. The purpose of this [...]

Background: Diagnostic errors (DEs), or the failure to accurately identify or provide timely explanations of a patient’s health problem, are a significant source of patient harm. DEs occur in up to 23% of adult inpatients who transfer to intensive care units (ICU) or die. Few studies have examined how clinician team composition impacts DE risk. [...]

Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is [...]

Background: Diagnostic errors have been cited as a potential contributor to hospital readmissions, particularly early readmissions (e.g. within 7 days), but little is known about their frequency and characteristics. We performed structured chart review of all medical patients readmitted within 7 days of discharge from a single academic medical center to describe the prevalence of [...]

Background: Diagnostic errors (DEs) represent ongoing threats to patient safety in the hospital. Little is known about the factors present on admission that can predict DE during the hospital encounter. Such knowledge is essential for prospective identification of hospitalized patients at risk for DE who can be targeted for early intervention. The purpose of this [...]

Background: It is important to understand knowledge about diagnostic error, such as cognitive bias and heuristics, for preventing a diagnostic error. However, it is unclear whether Japanese residents learn this knowledge. We aimed to assess diagnostic error knowledge in residents throughout Japan and compare it to the benchmark of the previous US score. In addition, [...]

Background: Medication errors are common, with more than half of patients estimated to have greater than or equal to one unintended medication discrepancy at hospital admission.  Medication reconciliation can identify errors. Although there has been significant investigation into the most effective logistical strategies for performing medicine reconciliation within the healthcare system, there is little investigation [...]