ArticleJournal of general internal medicine2026
Barriers to Leveraging Patient Safety Event Reviews for Organizational Learning, Improvement, and Diagnostic Error Reduction: Results of a Single Academic Center Survey Study.
Article in Journal of general internal medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Authors and funding
9 authors.
Funding
Abstract
backgroundDiagnostic errors represent a major cause of patient harm. One way to reduce diagnostic errors is to support learning health systems with standardized event review practices and data integration across event types and health systems. The extent to which this occurs and the barriers to doing so remain poorly characterized.
objectivesCharacterize event review practices and analyze the presence and distribution of key patient safety learning system constructs, diagnostic error analysis capabilities, and implementation barriers across a health system.
designWe developed a survey of participant safety event review practices, associated learning health system activities, diagnostic error analysis capabilities, data integration, and implementation barriers.
participantsThe survey was electronically distributed to a purposive sample of health system employees who routinely perform safety event reviews at one US academic medical center. APPROACH: Descriptive statistics were reported for survey constructs. Chi-square analysis was used to assess for non-response bias. KEY
resultsOne hundred and six of 249 possible respondents (42.6%) completed the survey. Safety event report review was the most frequently performed review type (85.5%) and legal claims review was the least frequent (17.0%). Only safety event report databases characterized diagnostic errors to a high degree (50.0%), while those for other event categories did so less frequently (< 30%). Few respondents reported tracking learnings across event categories (< 25% for all event types). Lack of dedicated review resources and supportive event review software were key barriers to learning and system improvement.
conclusionsThere is a need for more consistent practice across all safety event review types if learnings are to reduce diagnostic error and other drivers of patient harm. Organizations may benefit from standardization of review processes, databases that categorize diagnostic error within and across event review types, and resources to support reviews and translation of learnings into system improvement.
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Registered trials
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