We asked people working in four health care settings across Massachusetts, "How is your organization keeping patient safety at the forefront of its work, especially given uncertainty about the trajectory of the pandemic?"
A new framework categorizes diagnostic breakdowns that are unique to the ambulatory setting, where the majority of missed or delayed diagnoses occur. Developed by Boston-based researchers working with an advisory group half-comprised of patients and family caregivers, the framework is based on patient-reported errors in two national surveys.

In ambulatory care, patients and families may be the sole observers of process breakdowns that occur between office visits. And they often can see things, such as symptom changes and care at other settings, not visible to clinicians. When things don’t go well, patients and families can fill gaps in clinician-focused measures and contribute information that may otherwise go missing from organizational learning.

The researchers provide guidance for using the framework and offer an example of how it can be applied: a new online tool, OurDx, available in English and Spanish.

Use of telemedicine soared during the pandemic and, for many providers, it is here to stay. The Institute for Healthcare Improvement developed an approach for health care organizations to provide "safe, equitable, person-centered telemedicine.” Focused on six core elements — access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design — the white paper highlights the importance of maintaining key principles of safety and quality in telehealth services.

Upcoming events

  • IHI Forum 2021. From the Institute for Healthcare Improvement, the forum will give health care professionals a platform to learn and contribute to a shared vision of quality, equitable care for all. Attendees can expect practical learning sessions, 300+ speakers, keynote presentations and more. December 5 - 8. Learn more
Patient Safety Beat is published by the Betsy Lehman Center, a Massachusetts state agency that supports providers, patients and policymakers working together to advance the safety and quality of health care.