Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.  

This study of US primary care physicians tested their patient safety and quality knowledge. Five topic areas were assessed: 1) patient management, 2) radiation risk, 3) general safety and quality, 4) structure, process, and outcome, and, 5) quality and safety definitions. The average score was 48% correct, indicating additional education in patient safety and quality for practicing primary care physicians is needed.

Overuse, overdiagnosis, and overtreatment pose a continuing threat to patient safety. Citing several contributors to overuse at the system, clinician, and patient levels, this commentary discusses potential solutions including the Choosing Wisely campaign and patient education.

Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.

Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.

Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.

Incorrect use of medical devices can lead to unfavorable outcomes. In this study of 663 patients with asthma and/or chronic obstructive pulmonary disease (COPD), 41% demonstrated incorrect use of their inhaler. Incorrect use was more common among older patients and associated with more acute exacerbations.

Medication administration errors made by parent or caregivers can result in medication errors at home. This systematic review found that 30% to 80% of pediatric patients experience a medication error at home, and that the risk increases based on characteristics of the caregiver and if a prescription contains more than two drugs.

The patient-provider relationship plays an important role in the delivery of safe, quality health care.  Using electronic encounter notes, this qualitative study describes physician language used to express negative and positive attitudes toward the patient. While positive attitudes were generally expressed via explicit language (e.g., direct compliments), negative attitudes were not explicit and often expressed through questioning patient credibility, disapproval of patient reasoning or self-care, stereotyping, portraying the patient as difficult, and emphasizing physician authority over the patient.

Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.

The "July Effect" refers to the idea there may be an increase in medical errors in July when newly graduated medical students begin their residencies. In this retrospective chart review of podiatric surgery patients, researchers did not find any statistically significant difference in patient outcomes between surgeries performed during the first quarter of residency (July-September) and the last quarter (April-June). Results suggest robust resident training programs can limit errors that may otherwise occur during this time of transition.  

The July effect is a phenomenon that presumably results in poor care due to the annual en masse introduction of new doctors into practice. This commentary outlines factors undermining the safe influx of these new clinicians into active, independent practice. The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible.

Physician language choice can reflect implicit biases, which can compromise patient care. In this study, researchers conducted a content analysis of 600 clinic notes to explore how physicians communicate disbelief in medical records and racial and gender differences in the use of such language. Three linguistic features suggesting disbelief were identified: (1) use of quotes (e.g., patient had a “reaction” to the medication), (2) use of judgement words – such as “claims” or “insists” – that imply doubt, and (3) reporting patient experiences as hearsay (e.g., “the patient reports that the symptom started yesterday"). The researchers found that these linguistic features were more common in notes written about Black patients compared to white patients; no gender differences were identified.

Inadequate follow-up of diagnostic testing can lead to missed or delayed diagnoses. Based on interviews with healthcare workers at Veterans Affairs (VA) facilities across the United States, this qualitative study identified factors contributing to lack of timely follow-up of abnormal test results. The most commonly cited factors included trainee/resident involvement, absence of a process to address incidental findings on imaging, lack of standardized electronic health records (EHR) and related tracking systems, and lack of updated patient and provider contact information. The authors summarize participant recommendations to reduce missed test results.

Overdiagnosis is an emerging safety concern due to its potential to result in physical, financial, and emotional harm. Researchers surveyed 533 primary care practitioners (physicians, nurse practitioners, and physician assistants) and asked them to estimate the probability of disease for common conditions (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability. Findings indicate that significant overestimation of disease among all participating practitioners – likely due to overestimates of pretest probability – may contribute to overdiagnosis and overuse.

Balancing adequate supervision and autonomy for clinical trainees is an ongoing challenge. This study used qualitative methods to explore how general practice supervisors approach trainee help-seeking and in-consultation supervision. Findings highlight the role of entrustment processes between supervisor, trainee, and patient, and areas for improvement in the oversight of trainee consultations in general practice. A November 2018 Spotlight Case discusses the factors that determine entrustment decisions for trainees.

Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 

Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.