Over a three-year period, this study audio-recorded handoffs of outpatient clinics to a pediatric emergency department (ED) to determine whether use of a receiver-driven structured handoff intervention can reduce miscommunication and increase perceived quality, safety, and efficacy. Implementation of the tool resulted in a 23% relative reduction in miscommunication and in increased compliance with handoff elements, including illness severity, pending tests, contingency plans, and detailed callback requests, as well as improved perceptions of healthcare quality, safety, and efficiency.

This pre–post study aimed to increase error reporting by pediatric resident physicians and medical students. Residents and medical students reported more errors after implementation of a monthly educational conference in which event reports were reviewed. The authors conclude that trainee-led adverse event review conferences can increase event reporting.

Progress in patient safety has been limited by a lack of reliable measures. This problem is compounded in ambulatory care, as most existing metrics have sought to measure safety in hospitalized patients. This systematic review identified 182 published safety measures in primary care and categorized them according to Donabedian's triad and the safety target. The majority of metrics sought to measure safety in medication management, with laboratory testing and care coordination among the other types of safety issues being assessed. The authors note several limitations with the metrics they identified—most had not been validated, and there were no published measures identified for diagnostic error (despite increasing evidence that such errors are common in the outpatient setting). A PSNet interview discusses the challenges of measuring and improving safety in the ambulatory care environment.

This survey study found that most resident physicians did not use incident reporting systems for adverse events in which they were involved, often because they did not know what or how to report. These results highlight the shortcomings of voluntary reporting for patient safety.

This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.