Tom Augello

A new study that looks at when, where, and how medical errors occur in the in-patient setting is shining a bright light on threats to patient safety and quality in health care. A topline result of a 25 percent error rate for hospital admissions is getting a lot of attention. Lead author David Bates and others explain the implications for everyone in health care from the board room to the bedside.

Many patient safety initiatives fail to be adopted and implemented, even when proven effective. This creates the well-recognized know-do gap—which occurs when health care workers know what should be done based on evidence vs. what takes place in practice. To address this issue, CRICO funded the development of a patient safety adoption framework and had it evaluated by leaders in quality and safety. The framework and its findings were published online in the Journal of Patient Safety in April 2023.

One thing that seemed to be missing in this particular evaluation was a formal differential diagnosis that may have been present in the physician's brain, but wasn't documented, and there's no evidence that it was really thought about.