AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
Patient Safety in Ambulatory Care

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (37)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (79)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (189)

•Medical Complications (27)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (10)

•Transfusion Complications (2)

•Psychological and Social Complications (13)

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•Australia and New Zealand (10)

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Resource Types

•Audiovisual (4)

•Book/Report (27)

•Clinical Guideline (1)

•Journal Article (304)

•Legislation/Regulation (6)

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•Newspaper/Magazine Article (28)

•Press Release/Announcement (2)

•Special or Theme Issue (3)

•Tools/Toolkit (10)

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Error Types

•Epidemiology of Errors and Adverse Events (117)

•Active Errors (66)

•Latent Errors (18)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (85)

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•Error Reporting and Analysis (107)

•Communication Improvement (141)

•Human Factors Engineering (30)

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•Education and Training (58)

Clinical Areas

•Allied Health Services (4)

•Dentistry (1)

•Medicine (312)

•Nursing (11)

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Target Audience

•Health Care Providers (297)

•Health Care Executives and Administrators (239)

•Non-Health Care Professionals (150)

•Patients (29)

Setting of Care
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Ambulatory Care

•Home Care (25)

•Ambulatory Clinic or Office (122)

•Outpatient Pharmacy (16)

1 - 20 of 400

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STUDY

Adverse drug events resulting from patient errors in older adults.

Field TS, Mazor KM, Briesacher B, Debellis KR, Gurwitz JH. J Am Geriatr Soc. 2007;55:271-276.

STUDY

Pharmacologically inappropriate prescriptions for elderly patients in general practice: how common?

Brekke M, Rognstad S, Straand J, et al. Scand J Prim Health Care. 2008;26:80-85.

STUDY

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.

COMMENTARY

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.

Singh R, Singh A, Fox C, Seldan Taylor J, Rosenthal T, Singh G. Inform Prim Care. 2005;13:135-144.

STUDY

Educating seniors to be patient safety self-advocates in primary care.

Elder NC, Regan SL, Pallerla H, Levin L, Post DM, Cegala DJ. J Patient Saf. 2008;4:106-112.

STUDY

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

Brenner S, Detz A, López A, Horton C, Sarkar U. BMJ Qual Saf. 2012;21:670-675.

STUDY

Electronic medical record availability and primary care depression treatment.

Harman JS, Rost KM, Harle CA, Cook RL. J Gen Intern Med. 2012;27:962-967.

NEWSPAPER/MAGAZINE ARTICLE

Approved: 2010 National Patient Safety Goals.

Jt Comm Perspect. October 2009;29:1, 20-31.

BOOK/REPORT

Patient Safety in Primary Care.

Kingston-Riechers J, Ospina M, Jonsson E, Childs P, McLeod L, Maxted JM. Edmondton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541273.

BOOK/REPORT

Safety in Doses.

London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.

COMMENTARY classic

classic

Refocusing the lens: patient safety in ambulatory chronic disease care.

Sarkar U, Wachter RM, Schroeder SA, Schillinger D. Jt Comm J Qual Patient Saf. 2009;35:377-383.

NEWSPAPER/MAGAZINE ARTICLE

Why doctors make mistakes.

Groopman J. AARP Magazine. September/October 2008.

STUDY

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

Wessell AM, Nietert PJ, Jenkins RG, Nemeth LS, Ornstein SM. Am J Geriatr Pharmacother. 2008;6:21-27.

STUDY

In-home medication reviews: a novel approach to improving patient care through coordination of care.

Willis JS, Hoy RH, Jenkins WD. J Community Health. 2011;36:1027-1031.

STUDY

Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities.

Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Fam Pract. 2013;30:56-63.

TOOLKIT

Engaging Patients in Improving Ambulatory Care.

Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013.

STUDY

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. J Gen Intern Med. 2012;27:1416-1423.

STUDY

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

McGuire MJ, Noronha G, Samal L, Yeh HC, Crocetti S, Kravet S. J Gen Intern Med. 2013;28:184-192.

STUDY

Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network.

Wessell AM, Litvin C, Jenkins RG, Nietert PJ, Nemeth LS, Ornstein SM. Qual Saf Health Care. 2010;19:e21.

BOOK/REPORT

A Guide to Patient Safety in the Medical Practice.

Vance JE. Chicago, IL: American Medical Association; 2008. ISBN: 9781579476748.

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