AHRQ Patient Safety Network

The Collection > Ambulatory Care

PATIENT SAFETY PRIMERS
Patient Safety in Ambulatory Care

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Safety Target

•Device-related Complications (7)

•Diagnostic Errors (50)

•Identification Errors (11)

•Discontinuities, Gaps, and Hand-Off Problems (116)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (241)

•Medical Complications (27)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (9)

•Transfusion Complications (2)

•Psychological and Social Complications (18)

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (357)

•Legislation/Regulation (8)

•Meeting/Conference (6)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (32)

•Press Release/Announcement (6)

•Special or Theme Issue (8)

•Tools/Toolkit (13)

•Web Resource (10)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (129)

•Active Errors (98)

•Latent Errors (30)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (117)

•Legal and Policy Approaches (45)

•Error Reporting and Analysis (118)

•Communication Improvement (197)

•Human Factors Engineering (46)

•Teamwork (27)

•Specialization of Care (20)

•Logistical Approaches (28)

•Culture of Safety (53)

•Technologic Approaches (123)

•Education and Training (91)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (391)

•Health Care Executives and Administrators (292)

•Non-Health Care Professionals (177)

•Patients (42)

Setting of Care
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Ambulatory Care

•Home Care (30)

•Ambulatory Clinic or Office (175)

•Outpatient Pharmacy (43)

1 - 20 of 494

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REVIEW

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.

BOOK/REPORT

Safety in Doses.

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

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

STUDY

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

STUDY

Post-discharge medication reviews for patients with heart failure: a pilot study.

Ponniah A, Shakib S, Doecke CJ, Boyce M, Angley M. Pharm World Sci. 2008;30:810-815.

REVIEW

Routinely recorded patient safety events in primary care: a literature review.

Tsang C, Majeed A, Aylin P. Fam Pract. 2012;29:8-15.

STUDY

Information exchange among physicians caring for the same patient in the community.

van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-1018.

STUDY

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

Bell CM, Schnipper JL, Auerbach AD, et al. J Gen Intern Med. 2009;24:381-386.

BOOK/REPORT

Safety First: Top of Your Board's Agenda: 100 Day Challenge Survey Report.

The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.

STUDY

Improving medication safety in primary care using electronic health records.

Nemeth LS, Wessell AM. J Patient Saf. 2010;6:238-243.

STUDY

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

STUDY

Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events.

Metlay JP, Hennessy S, Localio AR, et al. J Gen Intern Med. 2008;23:1589-1594.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

STUDY

Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data.

McDonald KM, Davies SM, Haberland CA, et al. Pediatrics. 2008;122:e416-e425.

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

STUDY

Medication, allergy, and adverse drug event discrepancies in ambulatory care.

Stephens M, Fox B, Kukulka G, Bellamy J. Fam Medicine. 2008;40:107-110.

STUDY

Implementing medication reconciliation in outpatient pediatrics.

Rappaport DI, Collins B, Koster A, et al. Pediatrics. 2011;128:e1600-e1607.

NEWSPAPER/MAGAZINE ARTICLE

Rx for medication errors.

Friedley NJ. Med Econ. October 17, 2008;85:34-38.

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