Gordon Schiff

• Doctor of Medicine
• Brigham and Women's Hospital

Objective To analyse endometriosis diagnostic errors made by clinicians as reported by patients with endometriosis. Methods This study deductively analysed qualitative data as part of a larger mixed-methods research study examining ‘invalidating communication’ by clinicians concerning patients’ symptoms. Data analysed were responses to an open-end...

There is growing awareness of the need for more cautious, conservative prescribing. One conservative prescribing principle urges prescribers, whenever possible, to start only one new medication at a time. Little is known about how often primary care physicians (PCPs) start multiple medications at the same time, and when that is needed. To describe...

Background Wrong-drug medication errors are common. Regulators screen drug names for confusability, but screening methods lack empirical validation. Previous work showed that psycholinguistic tests on pairs of drug names are associated with real-world error rates in chain pharmacies. However, regulators evaluate individual names not pairs , and ind...

Objective Conduct systematic proactive pharmacovigilance screening for symptoms patients experienced after starting new medications using an electronic patient portal. We aimed to design and test the feasibility of the system, measure patient response rates, provide any needed support for patients experiencing potentially drug-related problems, and...

Pharmacists play a crucial role in medication safety and quality improvement in healthcare, yet face significant challenges due to limited data access, poor data quality, and insufficient data management skills. National pharmacy organizations emphasize the importance of pharmacists using data effectively to improve patient care. This paper suggest...

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, an...

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. Identify loop closure rates and vulnerable process points for patients with rectal bleeding. Retrospective cohort study, using medical record review of patie...

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...

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 encount...

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. image

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, acknowledge...

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...

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 ev...

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with...

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...

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 proce...

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 char...

The prosecution and ultimate conviction of nurse RaDonda Vaught is both a warning and a call to action for pharmacists and the profession of pharmacy. This essay outlines 9 steps that should be taken to maximize patient safety and minimize the risk of criminal prosecution for harm that result from human error. These include advocating for safe prac...

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...

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. We aimed to explore the perceptions and experiences of uncertainty among residents an...

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 opioi...

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. The rapid growth in national health expenditures can be addressed through a system that yields net savings over proj...

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 Rep...

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...

Importance: Progress in understanding and preventing diagnostic errors has been modest. New approaches are needed to help clinicians anticipate and prevent such errors. Delineating recurring diagnostic pitfalls holds potential for conceptual and practical ways for improvement. Objectives: To develop the construct and collect examples of "diagnos...

Background Benzodiazepines, opioids, proton-pump inhibitors (PPIs), and antibiotics are frequently prescribed inappropriately by primary care physicians (PCPs), without sufficient consideration of alternative options or adverse effects. We hypothesized that distinct groups of PCPs could be identified based on their propensity to prescribe these med...

Background: Problem lists represent an integral component of high-quality care. However, they are often inaccurate and incomplete. We studied the effects of alerts integrated into the inpatient and outpatient computerized provider order entry systems to assist in adding problems to the problem list when ordering medications that lacked a correspon...

Background Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%–73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their val...

Purpose: Studies demonstrate how patient roles in system redesign teams reflect a continuum of involvement and influence. This research shows the process by which patients move through this continuum and effectively engage within redesign projects. Design/methodology/approach: The authors studied members of redesign teams, consisting of 5-10 mem...

COVID-19 necessitated significant care redesign, including new ambulatory workflows to handle surge volumes, protect patients and staff, and ensure timely reliable care. Opportunities also exist to harvest lessons from workflow innovations to benefit routine care. We describe a dedicated COVID-19 ambulatory unit for closing testing and follow-up lo...

Importance More conservative prescribing has the potential to reduce adverse drug events and patient harm and cost; however, no method exists defining the extent to which individual clinicians prescribe conservatively. One potential domain is prescribing a more limited number of drugs. Personal formularies—defined as the number and mix of unique, n...

Background: The relationship between clinician and patient is the cornerstone of primary care. Breakdown and termination of this relationship are understudied yet important, undesirable outcomes. Objective: To better understand the nature and extent of provider and clinic termination of the primary care relationship. Design: Retrospective obse...

Background: Clinicians frequently order urine drug testing (UDT) for patients on chronic opioid therapy (COT), yet often have difficulty interpreting test results accurately. Objectives: To evaluate the implementation and effectiveness of a laboratory-generated urine toxicology interpretation service for clinicians prescribing COT. Study design...

Diagnostic errors are a source of unacceptable harm in health care. However, improvement efforts have been hampered by the lack of valid measures reflecting the quality of the diagnostic process. At the same time, it has become apparent that the healthcare work system, particularly in primary care, is chaotic and stressful, leading to clinician bur...

Importance Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). Previous research shows that interruptive solutions, such as electronic patient verification forms or alerts...

The commentary below was written by Dr. Gordon Schiff and Maria Mirica for the PRIDE (Primary Care Research in Diagnostic Errors) project, an initiative of the Betsy Lehman Center for Patient Safety and Brigham and Women's Hospital Center for Patient Safety Research and Practice with support from the Gordon and Betty Moore Foundation. It highlights...

It is 5 pm on Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expec...

These are trying times for the patient-physician relationship.¹,2 Patients frequently report that their physician is not listening or, at least, that they do not feel heard.³ Some research suggests they are right—sometimes their physicians are not listening.⁴,5 Appointment times, although short, are longer than in the past and have increased from j...

Background The essence of humanism in medicine and health care is relationships—caring relationships between clinicians and patients. While raising concerns regarding professional-patient boundaries has positively contributed to our understanding and prevention of potentially harmful boundary violations, there is controversy about which types of re...

Background Urine drug testing (UDT) is an essential tool to monitor opioid misuse among patients on chronic opioid therapy. Inaccurate interpretation of UDT can have deleterious consequences. Providers’ ability to accurately interpret and document UDT, particularly definitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) results, has no...

Background: Clinical decision support (CDS) alerting tools can identify and reduce medication errors. However, they are typically rule-based and can identify only the errors previously programmed into their alerting logic. Machine learning holds promise for improving medication error detection and reducing costs associated with adverse events. Thi...

Background To assess the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. Setting Urban, academic medical centre, comprising a 495-bed hospital and outpatient clinic running on the Cerner EHR. We extracted 8 years of medication orders and diagnostic c...

Background: In the ambulatory setting, missed cancer diagnoses are leading contributors to patient harm and malpractice risk; however, there are limited data on the malpractice case characteristics for these cases. Objective: The aim of this study was to examine key features and factors identified in missed cancer diagnosis malpractice claims fi...

Purpose: To examine the extent to which outpatient clinicians currently document drug indications in prescription instructions. Methods: Free-text sigs were extracted from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. Natural language processing wa...

Importance Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records...

Importance: The indication (reason for use) for a medication is rarely included on prescriptions despite repeated recommendations to do so. One barrier has been the way existing electronic prescribing systems have been designed. Objective: To evaluate, in comparison with the prescribing modules of 2 leading electronic health record prescribing s...

Purpose An ethnographic study of 3 pharmacy and therapeutics (P&T) committees was conducted to characterize the process by which evidence is weighted and decisions are made. Methods We recorded discussions and conducted an analysis of the transcripts from the 3 P&T committees for a 1-year period. We examined the content and ideas expressed during...

While electronic prescribing has been shown to reduce medication errors and improve prescribing safety, it is vulnerable to error-prone processes. We review six intersecting areas in which changes to electronic prescribing systems, particularly in the outpatient setting, could transform medication ordering quality and safety. We recommend incorpora...

Background Medication adverse events are important and common yet are often not identified by clinicians. We evaluated an automated telephone surveillance system coupled with transfer to a live pharmacist to screen potentially drug-related symptoms after newly starting medications for four common primary care conditions: hypertension, diabetes, dep...

Objective: To extract drug indications from a commercial drug knowledgebase and determine to what extent drug indications can discriminate between look-alike-sound-alike (LASA) drugs. Methods: We extracted drug indications disease concepts from the MedKnowledge Indications module from First Databank Inc. (South San Francisco, CA) and associated...

Objective Hospitalized patients often receive opioids. There is a lack of consensus regarding evidence-based guidelines or training programs for effective management of pain in the hospital. We investigated the viability of using an Internet-based opioid dosing simulator to teach residents appropriate use of opioids to treat and manage acute pain....

Background: Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue. Objective: To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates....

Purpose: The incorporation of medication indications into the prescribing process to improve patient safety is discussed. Summary: Currently, most prescriptions lack a key piece of information needed for safe medication use: the patient-specific drug indication. Integrating indications could pave the way for safer prescribing in multiple ways, i...

Background Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Au...

Background Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous. Objective To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous. Methods During a nearly 3 year retrospe...

Background. Look-alike, sound-alike (LASA) drug names are a cause of medication errors with resulting patient harm and healthcare costs. This study assessed to which extent the use of the generic drug name, therapeutic class, health problem, and the U.S. Food and Drug Administration (FDA)-approved indications might be used to differentiate LASA dru...

Objective Medication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors...

As clinical notes become increasingly and universally electronic, there are a series of key opportunities and challenges facing users and developers of this technology. An emerging series of "chief complaints" are being heard from clinicians using electronic records, both in terms of dissatisfaction with workflow and time entailed in entering their...

Objective: Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. Study setting: In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. Study design: Controlled trial of a 15-month intervention including exposure to a learning network, webina...

To reduce the risk of wrong-patient errors, safety experts recommend limiting the number of patient records providers can open at once in electronic health records (EHRs). However, it is unknown whether health care organizations follow this recommendation or what rationales drive their decisions. To address this gap, we conducted an electronic surv...

Purpose The development and evaluation of an algorithm for detecting potential medication errors due to look-alike/sound-alike (LASA) drug names are described. Summary A computer algorithm that detects potential LASA errors by analyzing medication orders and diagnostic claims data was developed. The algorithm flags a potential error when (1) a med...

Purpose The variations in how drug names are displayed in computerized prescriber-order-entry (CPOE) systems were analyzed to determine their contribution to potential medication errors. Methods A diverse set of 10 inpatient and outpatient CPOE system vendors and self-developed CPOE systems in 6 U.S. healthcare institutions was evaluated. A team o...

Background: Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. Methods: The project featured triannual learning se...

Objective: Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. Materials and Methods: We examined medication orders from an academic medical center for a 6-year period (2006–2011; n = 5 804 150)...

Objective: The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication error alerts generated by an alerting system using outlier detection screening. Materials and methods: Five years of clinical data were extracted from an electronic health record system for 747 985 patients who had at least one visit duri...

In a Perspective, Gordon Schiff discusses the importance of appropriately analyzing adverse event reports.

Objective To examine medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them. Materials and Methods We reviewed all patient safety medication reports that occurred in the medication ordering phase from 6 sites participating in a United States Food and Drug Admi...

This interactive feature on weight loss offers a case vignette accompanied by essays that support either using an FDA-approved drug as an aid or maximizing lifestyle modification and nonpharmacologic therapies. Share your comments and vote at NEJM.org.

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, ‘Improving Diagnosis in Health Care’, con...

Pain care for hospitalized patients is often suboptimal. Representing pain scores as a graphical trajectory may provide insights into the understanding and treatment of pain. We describe a 1-year, retrospective, observational study to characterize pain trajectories of hospitalized adults during the first 48 hours after admission at an urban academi...

"In our current era of transparent, patient-centered medicine, such sentiments would hardly be accepted. Unfortunately, patients are often still in the dark regarding the purposes of their medications. It is said that there are five “rights” required for safe medication ordering and use: the right patient, the right drug, the right dose, the right...

Background: How some organizations improve while others remain stagnant is a key question in health care research. Studies identifying how organizations can implement improvement despite barriers are needed, particularly in primary care. Purposes: This inductive qualitative study examines primary care clinics implementing improvement efforts in...

Background Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their poten...

Important safety concerns have recently emerged regarding the use of sodium polystyrene sulfonate (Kayexalate), a cation-exchange resin commonly used for the treatment of hyperkalemia. We implemented an electronic alert system at a tertiary care academic medical center to warn providers of the safety concerns of Kayexalate. We assessed the number o...