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 (39)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (91)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (245)

•Medical Complications (35)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (18)

•Transfusion Complications (2)

•Psychological and Social Complications (11)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (8)

Resource Types

•Clinical Guideline (1)

•Journal Article (348)

•Legislation/Regulation (7)

•Meeting/Conference (7)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (32)

•Press Release/Announcement (6)

•Special or Theme Issue (6)

•Tools/Toolkit (12)

•Web Resource (11)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (138)

•Active Errors (82)

•Latent Errors (23)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (108)

•Legal and Policy Approaches (47)

•Error Reporting and Analysis (109)

•Communication Improvement (163)

•Human Factors Engineering (40)

•Teamwork (19)

•Specialization of Care (21)

•Logistical Approaches (32)

•Culture of Safety (42)

•Technologic Approaches (153)

•Education and Training (77)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (396)

•Health Care Executives and Administrators (298)

•Non-Health Care Professionals (170)

•Patients (32)

Setting of Care
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Ambulatory Care

•Home Care (27)

•Ambulatory Clinic or Office (164)

•Outpatient Pharmacy (34)

1 - 20 of 474

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STUDY

FDA drug prescribing warnings: is the black box half empty or half full?

Wagner AK, Chan KA, Dashevsky I, et al. Pharmacoepidemiol Drug Safety. 2006;15:369-386.

REVIEW

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

Fischer SH, Tjia J, Field TS. J Am Med Inform Assoc. 2010;17:631-636.

COMMENTARY

Medication Reconciliation Victory after an Avoidable Error

Cutler TW. AHRQ WebM&M [serial online]. February/March 2009.

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

Underdiagnosis of hypertension using electronic health records.

Banerjee D, Chung S, Wong EC, Wang EJ, Stafford RS, Palaniappan LP. Am J Hypertens. 2012;25:97-102.

REVIEW

Evaluation and certification of computerized physician order entry systems.

Classen D, Avery AJ, Bates DW. J Am Med Inform Assoc. 2007;14:48-55.

STUDY

Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia.

Lau DT, Mercaldo ND, Shega JW, Rademaker A, Weintraub S. Am J Alzheimers Dis Other Demen. 2011;26:606-615.

COMMENTARY

Patient safety beyond the hospital.

Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.

STUDY

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

Berner ES, Houston TK, Ray MN, et al. J Am Med Inform Assoc. 2006;13:171-179.

STUDY

The costs associated with adverse drug events among older adults in the ambulatory setting.

Field TS, Gilman BH, Subramanian S, Fuller JC, Bates DW, Gurwitz JH. Med Care. 2005;43:1171-1176.

STUDY

Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.

Simon SR, Smith DH, Feldstein AC, et al. J Am Geriatr Soc. 2006;54:963-968.

STUDY

Inappropriate medication in a national sample of US elderly patients receiving home health care.

Bao Y, Shao H, Bishop TF, Schackman BR, Bruce ML. J Gen Intern Med. 2012;27:304-310.

STUDY

Improving medication safety in primary care using electronic health records.

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

ORGANIZATIONAL POLICY/GUIDELINES

AORN guidance statement: "do-not-use" abbreviations, acronyms, dosage designations, and symbols.

AORN J. 2006;84:489-492.

MULTI-USE WEBSITE

National Patient Safety Awareness Week.

National Patient Safety Foundation.

STUDY

Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls.

Stauffer BD, Fullerton C, Fleming N, et al. Arch Intern Med. 2011;171:1238-1243.

MEETING/CONFERENCE PROCEEDINGS

2005 Annual Patient Safety and Health Information Technology Conference: Making the Health Care System Safer through Implementation and Innovation.

Agency for Healthcare Research and Quality. June 6-10, 2005.

COMMENTARY classic

Healthcare in a land called PeoplePower: nothing about me without me.

Delbanco T, Berwick DM, Boufford JI, et al. Health Expect. 2001;4:144-150.

STUDY

Inadequate health literacy among paid caregivers of seniors.

Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. J Gen Intern Med. 2011;26:474-479.

STUDY

Medication safety in primary care practice: results from a PPRNet quality improvement intervention.

Wessell AM, Ornstein SM, Jenkins RG, Nemeth LS, Litvin CB, Nietert PJ. Am J Med Qual. 2013;28:16-24.

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