… Improving medication safety in ambulatory care settings is a patient safety priority . This qualitative study with …

Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.

Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.

… barriers and facilitators of medication safety is a patient safety research priority. In this systematic review … rather than actual harms. … Young RA, Fulda KG, Espinoza A, et al. Ambulatory medication safety in primary care: a systematic review. J Am Board Fam Med. 2022;35(3):610-628. …

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

… to ensure safe transitions. … Wooldridge AR, Carayon P, Hoonakker P, et al. Care transition of trauma patients: Processes with …

… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: …

… team, including being heard, respected, and treated as a whole person. … Lasser EC, Heughan JA, Lai AY, et al. Patient perceptions of safety in primary care: a qualitative study to inform care. Curr Med Res Opin. Epub …

… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …

… coordinated, accessible health care. This study used a consensus process with input from a physician panel to examine ambulatory patient safety … of patient safety practices . … Oberlander T, Scholle SH, Marsteller J, et al. Implementation of patient safety …

… formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

… factors with patient safety culture in medical homes: a coincidence analysis. J Patient Saf. Epub 2020 Aug 3. …

… response, using the example of workflow redesigns in a pediatric ambulatory care clinic.  The authors discuss …

Care transitions increase the risk of patient safety events, and pediatric patients are particularly vulnerable. This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions, identify system barriers and solutions to guide efforts towards improving care transitions. Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; ED decision making; interacting with family; physical environment; role ambiguity; staffing/resources; team cognition; technology, and; characteristics of trauma care.  Understanding these barriers and facilitators can guide future endeavors to improve care transitions.

… and barriers to fulfilling these roles. Role ambiguity was a consistent finding in all three groups highlighting the …

Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.

Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

… In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by …

… Hosp Epidemiol … Health care–associated infections are a persistent challenge in all care environments. This … infections to spread. The authors recommend applying a human factors engineering model in these settings to reduce …

… Risk Manag … This commentary describes the application of a work system model to discharge transitions as a communication improvement strategy. The authors suggest …