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PSNet: Patient Safety Network
Journal Article

Safety incidents in the primary care office setting.

Rees P, Edwards A, Panesar S, et al. Pediatrics. 2015;135:1027-35.

Patient safety in outpatient settings is a growing concern. In this analysis of voluntarily reported safety events from the United Kingdom, researchers identified serious risks for children cared for in outpatient family medicine settings. Medication management, diagnostic errors, and errors in the referral process contributed significantly to patient harm, echoing prior studies about outpatient safety. The authors call for implementation of safety practices such as barcode medication administration, clinical decision support software, and electronic referral tracking, all of which remain incompletely implemented in ambulatory care. Given the known under-reporting of adverse events, this report likely underestimates the frequency of patient safety problems in this outpatient setting and emphasizes the need for active safety monitoring.