Incidence, Recognition, and Follow-up of Laboratory Evidence of Acute Kidney Injury in Primary Care Practices: Analysis of 93,259 Creatinine Results.

Background: Community-acquired acute kidney injury (CA-acute kidney injury) is under-recognized in the outpatient setting and is associated with adverse outcomes.

Methods: We analyzed the incidence of CA-acute kidney injury in an academic primary care practice and community health center and assessed recognition and follow-up as determined by repeat creatinine measurement (closed-loop). We reviewed 93,259 specimens for 36,593 unique patients from January 1, 2018, through December 31, 2021.

Clinician Ordering and Management Patterns of Urine Toxicology Results at a Cancer Center.

Context: Opioid therapy is a cornerstone for treatment of cancer-related pain, but standardized management practices for patients with cancer and aberrant urine drug test (UDT) results are lacking.

Objectives: To identify the prevalence of UDT ordering (both screening and definitive testing) in the oncology setting and to examine clinician management practices for patients with cancer on opioid therapy with aberrant definitive UDT results.

Methods: We conducted a retrospective chart review of patients with cancer on opioid therapy at an academic cancer center in the United States.

Do patients who read visit notes on the patient portal have a higher rate of "loop closure" on diagnostic tests and referrals in primary care? A retrospective cohort study.

Objectives: The 2021 US Cures Act may engage patients to help reduce diagnostic errors/delays. We examined the relationship between patient portal registration with/without note reading and test/referral completion in primary care.

Materials And Methods: Retrospective cohort study of patients with visits from January 1, 2018 to December 31, 2021, and order for (1) colonoscopy, (2) dermatology referral for concerning lesions, or (3) cardiac stress test at 2 academic primary care clinics.

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees.

Background: A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure.

Completion of Recommended Tests and Referrals in Telehealth vs In-Person Visits.

Importance: Use of telehealth has increased substantially in recent years. However, little is known about whether the likelihood of completing recommended tests and specialty referrals-termed diagnostic loop closure-is associated with visit modality.

Objectives: To examine the prevalence of diagnostic loop closure for tests and referrals ordered at telehealth visits vs in-person visits and identify associated factors.

Completion Rates and Timeliness of Diagnostic Colonoscopies for Rectal Bleeding in Primary Care.

Background: Rectal bleeding is the most common presenting symptom of colorectal cancer, and guidelines recommend timely follow-up, usually with colonoscopy to ensure timely diagnoses of colorectal cancer.

Objective: Identify loop closure rates and vulnerable process points for patients with rectal bleeding.

Design: Retrospective cohort study, using medical record review of patients aged ≥ 40 with index diagnosis of rectal bleeding at 2 primary practices-an urban academic practice and affiliated community health center, between January 1, 2018, and December 31, 2020.

Diagnostic excellence in primary care.

Diagnostic excellence is based on six fundamental principles of healthcare quality proposed by the Institute of Medicine in 2001, which state that diagnoses must be safe, effective, patient-centered, timely, efficient, and equitable.

How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care.

Objectives: The quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout.

Developing a Framework and Electronic Tool for Communicating Diagnostic Uncertainty in Primary Care: A Qualitative Study.

Importance: Communication of information has emerged as a critical component of diagnostic quality. Communication of diagnostic uncertainty represents a key but inadequately examined element of diagnosis.

Objective: To identify key elements facilitating understanding and managing diagnostic uncertainty, examine optimal ways to convey uncertainty to patients, and develop and test a novel tool to communicate diagnostic uncertainty in actual clinical encounters.

Exploring relationships between physician stress, burnout, and diagnostic elements in clinician notes.

Objectives: To understand the relationship between stressful work environments and patient care by assessing work conditions, burnout, and elements of the diagnostic process.

Methods: Notes and transcripts of audiotaped encounters were assessed for verbal and written documentation related to psychosocial data, differential diagnosis, acknowledgement of uncertainty, and other diagnosis-relevant contextual elements using 5-point Likert scales in seven primary care physicians (PCPs) and 28 patients in urgent care settings. Encounter time spent vs time needed (time pressure) was collected from time stamps and clinician surveys.

Closing the Loop: Re-engineering the Assessment and Tracking of Symptoms in Primary Care.

Reliable systems that track the continuation, progression, or resolution of a patient's symptoms over time are essential for reliable diagnosis and ensuring that patients harboring more worrisome diagnoses are safely followed up. Given their first-contact role and increasing stresses on busy primary care clinicians and practices, new processes that make these tasks easier rather than creating more work for busy clinicians are especially needed.Some symptoms are sufficiently worrisome that they demand an urgent diagnosis and treatment while others result in a differential that can be more safely explored over time, or less differentiated and worrisome that they are best managed with the "test of time" to see if they resolve, worsen, or evolve into symptoms that are more worrisome.

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

Ideally, urgent dermatology referrals for evaluation of a lesion concerning for skin cancer should be triaged and processed with appropriate urgency by primary care and dermatology, respectively. We performed a retrospective single-institution study by conducting chart reviews of all dermatology referrals designated by primary care as urgent for evaluation of a lesion concerning for skin cancer. We identified 320 referrals placed between January 1 and December 31, 2018.

Pharmacists' role in detection and evaluation of adverse drug reactions: Developing proactive systems for pharmacosurveillance.

Purpose: To identify current challenges in detection of medication-related symptoms, and review technology-based opportunities to increase the patient-centeredness of postmarketing pharmacosurveillance to promote more accountable, safer, patient-friendly, and equitable medication prescribing.

Summary: Pharmacists have an important role to play in detection and evaluation of adverse drug reactions (ADRs). The pharmacist's role in medication management should extend beyond simply dispensing drugs, and this article delineates the rationale and proactive approaches for pharmacist detection and assessment of ADRs.

Improving diagnosis: adding context to cognition.

Background: The environment in which clinicians provide care and think about their patients is a crucial and undervalued component of the diagnostic process.

Content: In this paper, we propose a new conceptual model that links work conditions to clinician responses such as stress and burnout, which in turn impacts the quality of the diagnostic process and finally patient diagnostic outcomes. The mechanism for these interactions critically depends on the relationship between working memory (WM) and long-term memory (LTM), and ways WM and LTM interactions are affected by working conditions.

Analysis of Radiology Report Recommendation Characteristics and Rate of Recommended Action Performance.

Importance: Following up on recommendations from radiologic findings is important for patient care, but frequently there are failures to carry out these recommendations. The lack of reliable systems to characterize and track completion of actionable radiology report recommendations poses an important patient safety challenge.

Objectives: To characterize actionable radiology recommendations and, using this taxonomy, track and understand rates of loop closure for radiology recommendations in a primary care setting.

Anatomy of diagnosis in a clinical encounter: how clinicians discuss uncertainty with patients.

Background: Studies consider the clinical encounter as linear, comprising six phases (opening, problem presentation, history-taking, physical examination, diagnosis, treatment and closing). This study utilizes formal conversation analysis to explore patient-physician interactions and understanding diagnostic utterances during these phases.

Methods: This study is a qualitative sub-analysis that explores how the diagnosis process, along with diagnostic uncertainty, are addressed during 28 urgent care visits.

The impact of clinical uncertainty in the graduate medical education (GME) learning environment: A mixed-methods study.

Background: Uncertainty is ubiquitous in medicine. Studies link intolerance of uncertainty to burnout, ineffective communication, cognitive bias, and inappropriate resource use. Little is known about how uncertainty manifests in the clinical learning environment.

Lessons Learned in Implementing a Chronic Opioid Therapy Management System.

Objectives: Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization.

The American Public Health Association Endorses Single-Payer Health System Reform.

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system.

Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events.

Objectives: A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent to which healthcare organizations can aggregate, analyze, share, and learn from these events. In response to this problem, the Agency for Healthcare Research and Quality (AHRQ) began the development of the Common Formats for Event Reporting for Diagnostic Safety Events (CFER-DS). We conducted a usability assessment of the draft CFER-DS to inform future revision and implementation.

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

Background: In response to the complexity, challenges, and slow pace of innovation, health care organizations are adopting interdisciplinary team approaches. Systems engineering, which is oriented to creating new, scalable processes that perform with higher reliability and lower costs, holds promise for driving innovation in the face of challenges to team performance. A patient safety learning laboratory (lab) can be an essential aspect of fostering interdisciplinary team innovation across multiple projects and organizations by creating an ecosystem focused on deploying systems engineering methods to accomplish process redesign.