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 (9)

•Diagnostic Errors (60)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (109)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (303)

•Medical Complications (36)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (18)

•Transfusion Complications (2)

•Psychological and Social Complications (19)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (15)

Resource Types

•Clinical Guideline (1)

•Journal Article (428)

•Legislation/Regulation (10)

•Meeting/Conference (5)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (6)

•Special or Theme Issue (7)

•Tools/Toolkit (17)

•Web Resource (13)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (166)

•Active Errors (127)

•Latent Errors (42)

•Near Miss (10)

Approach to Improving Safety

•Quality Improvement Strategies (137)

•Legal and Policy Approaches (64)

•Error Reporting and Analysis (149)

•Communication Improvement (212)

•Human Factors Engineering (57)

•Teamwork (28)

•Specialization of Care (20)

•Logistical Approaches (40)

•Culture of Safety (54)

•Technologic Approaches (157)

•Education and Training (100)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (473)

•Health Care Executives and Administrators (334)

•Non-Health Care Professionals (203)

•Patients (62)

Setting of Care
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Ambulatory Care

•Home Care (33)

•Ambulatory Clinic or Office (219)

•Outpatient Pharmacy (76)

1 - 20 of 598

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COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

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.

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

STUDY

Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.

Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

NEWSPAPER/MAGAZINE ARTICLE

Rx for medication errors.

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

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.

BOOK/REPORT

Managing Patients' Medicines after Discharge from Hospital.

London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.

FACT SHEET/FAQS

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.

Institute of Safe Medication Practices. 2011.

STUDY

Frequency of failure to inform patients of clinically significant outpatient test results.

Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-1129.

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.

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.

COMMENTARY

Lethal Cap.

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

TOOLKIT

Engaging Patients in Improving Ambulatory Care.

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

STUDY

Approaches to reducing the most important patient errors in primary health-care: patient and professional perspectives.

Buetow S, Kiata L, Liew T, Kenealy T, Dovey S, Elwyn G. Health Soc Care Community. 2010;18:296-303.

STUDY

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

Stewart AL, Lynch KJ. J Am Pharm Assoc (2003). 2012;52:59-66.

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.

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.

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.

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