This qualitative evaluation found that the AHRQ Improving Your Office Testing Process toolkit was perceived as usable and applicable to the clinical setting. The content for patient engagement and communication with test results was particularly valued.

Insufficient communication of laboratory test results can contribute to delays in diagnosis. Discussing poor communication regarding test results in primary care, this commentary advocates for research to understand the best ways to notify patients about their results and involve patients in shared decision-making so that they understand the physician's interpretation and recommendations.

This study describes the successful implementation of a Web-based reporting system for near-miss events in primary care practices. The most prevalent reports were breakdowns in office processes, with varying risk for adverse events, as found in prior studies of incident reporting. Although near-miss reporting can stimulate improvement efforts, it is not a precise method for detecting safety problems.

Examining patient safety in home hospice care, the authors found that falls and inadequate symptom control (an error of omission) were the most common concerns, often related to patient or family caregiver actions rather than the home hospice team. This study reveals unique safety considerations around providing end-of-life care for patients.

Electronic health records (EHRs) hold great promise for improving patient safety, but remain underutilized, especially in ambulatory care settings. Failure to appropriately follow up on abnormal test results is a common ambulatory care safety problem, and has been implicated in malpractice lawsuits arising from missed or delayed diagnoses. In this study conducted at eight family medicine clinics, those with an EHR documented clinician and patient notification of abnormal test results and clear follow-up plans more often than those with paper charts. However, even in clinics using EHRs, more than one-third of abnormal results had no follow-up plan documented. This finding corroborates prior research that clinician notification alone does not ensure timely and complete follow-up of test results.

This study evaluated contributing factors to effective test management systems and identified safety awareness and technological adoption as two themes worthy of greater attention in system design.

Developing and promoting incident reporting systems is essential to ensuring a culture of safety. However, many barriers—real and perceived—prevent frontline clinicians from reporting errors. This study compared nurses' responses during focus groups to institutional safety culture measurements, and found that although nurses reported adequate access to reporting systems, few actually reported errors, for both practical and cultural reasons. An AHRQ WebM&M commentary discusses a case where a nurse was discouraged from reporting a medication error.

This study describes the impact of a pilot intervention focused on educating and improving the capacity of elderly patients to communicate with their health care providers. The authors found that the time-intensive effort can improve patients' self-reported behaviors and their safety knowledge.

This study discusses the development of a survey tool to assess elderly patients' ability to engage in patient safety behaviors as well as their comfort discussing patient safety with their physicians.

The authors used community-based participatory research to learn about consumers' definitions of medical errors and types of harm from these errors.

While incident reporting is an accepted method of error detection in the inpatient setting, it remains underutilized in ambulatory practice. In this survey, researchers conducted focus groups with physicians, nurses, and office staff around the issue of error reporting. Respondents reported that logistical factors were the major barrier to reporting errors, principally the additional effort required to report an error and lack of clear guidelines on which errors should be reported and how much information should be provided. A prior study found similar concerns among inpatient-based providers.

The investigators qualitatively analyzed error reports from the primary care setting in which an error had been caught before it caused patient harm.

The investigators conducted surveys and literature review to explore how family physicians identified error and found little agreement on what constituted error both in the field and the research base.

This survey of primary care practices found that, while sample medications were dispensed at nearly 10% of patient encounters, most clinics did not follow the Institute for Safe Medication Practices' recommendations for safe distribution of medication samples.

This AHRQ–funded study discovered differential reporting patterns among staff, clinicians, and patients in 10 family medicine clinics. Using anonymous reporting systems during a defined study period, investigators analyzed more than 900 errors generated by an even distribution of reports from staff and clinicians. However, while staff focused on errors in patient flow and communication, clinicians noted mostly medication- and laboratory-related errors. Overall, the large majority of errors were classified as process errors rather than as knowledge- and skill-related errors. Very few patient-generated reports described an error, suggesting that different strategies may be required to engage patients in similar reporting efforts.

The investigators in this Agency for Healthcare Research and Quality-sponsored study determined that pharmacists contact primary care practices most frequently to clarify prior authorization, formulary issues, and unclear or missing dosages.

The investigators interviewed patients to determine their reactions after experiencing preventable medical errors.

This survey of 253 primary care clinicians revealed that important clinical information was missing in nearly 1 in 7 visits, and providers believed this missing information could adversely affect patient care.