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 (11)

•Diagnostic Errors (49)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (147)

•Medical Complications (32)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (11)

•Transfusion Complications (2)

•Psychological and Social Complications (5)

Origin/Sponsor

•Australia and New Zealand (9)

•North America (225)

Resource Types

•Audiovisual (3)

•Book/Report (29)

•Clinical Guideline (1)

•Journal Article (185)

•Legislation/Regulation (8)

•Meeting/Conference (6)

•Newspaper/Magazine Article (19)

•Press Release/Announcement (8)

•Special or Theme Issue (7)

•Tools/Toolkit (7)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (67)

•Active Errors (71)

•Latent Errors (25)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (84)

•Legal and Policy Approaches (30)

•Error Reporting and Analysis (67)

•Communication Improvement (106)

•Human Factors Engineering (46)

•Teamwork (8)

•Specialization of Care (10)

•Logistical Approaches (20)

•Culture of Safety (22)

•Technologic Approaches (63)

•Education and Training (64)

Clinical Areas

•Allied Health Services (1)

•Complementary and Alternative Medicine (1)

•Dentistry (5)

•Medicine (200)

•Pharmacy (63)

Target Audience

•Health Care Providers (255)

•Health Care Executives and Administrators (179)

•Non-Health Care Professionals (85)

•Patients (28)

Setting of Care
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Ambulatory Care

•Home Care (21)

•Ambulatory Clinic or Office (71)

•Outpatient Pharmacy (12)

1 - 20 of 283

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PRESS RELEASE/ANNOUNCEMENT

Maalox Total Relief and Maalox Liquid Products: Medication Use Errors.

MedWatch Safety Alert. Rockville, MD: US Food and Drug Administration; February 17, 2010.

PRESS RELEASE/ANNOUNCEMENT

Important change to heparin container labels to clearly state the total drug strength.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.

STUDY

Implementing patient safety practices in small ambulatory care settings.

Schauberger CW, Larson P. Jt Comm J Qual Patient Saf. 2006;32:419-425.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

BOOK/REPORT

Review of Patient Safety for Children and Young People.

London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071.

NEWSPAPER/MAGAZINE ARTICLE

Small patients, big consequences in medical errors.

Tarkan L. New York Times. September 14, 2008;Health section:7.

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.

PRESS RELEASE/ANNOUNCEMENT

Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically.

National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System Pharmacists and Institute for Safe Medication Practices; January 23, 2013.

STUDY

Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting.

Söderberg J, Grankvist K, Brulin C, Wallin O. Scand J Clin Lab Invest. 2009;69:731-735.

COMMENTARY

Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad

Ranji S. AHRQ WebM&M [serial online]. April 2008.

COMMENTARY

To LP or not LP.

Landrigan CP. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

Disruptive clinician behavior: a persistent threat to patient safety.

Porto G, Lauve R. Patient Safety Qual Healthc. July/August 2006;3:16-24.

STUDY

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

Tjia J, Field TS, Garber LD, et al. Am J Manag Care. 2010;16:489-496.

BOOK/REPORT

Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.

Atlanta, GA: Centers for Disease Control and Prevention; 2011.

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.

REVIEW

Clinical dilemmas and a review of strategies to manage drug shortages.

Rider AE, Templet DJ, Daley MJ, Shuman C, Smith LV. J Pharm Pract. 2013 Apr 3; [Epub ahead of print].

STUDY

Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.

Hayes BD, Klein-Schwartz W. Clin Toxicol (Phila). 2010;48:68-71.

MEETING/CONFERENCE PROCEEDINGS

July 2011 Author in the Room Teleconference.

Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.

STUDY

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Altfeld SJ, Shier GE, Rooney M, et al. Gerontologist. 2012 Sep 7; [Epub ahead of print].

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