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The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  
Lindblad M, Unbeck M, Nilsson L, et al. BMC Health Serv Res. 2020;20:289.
This study used a trigger tool to retrospectively identify and characterize no-harm incidents affecting adult patients in home healthcare settings in Sweden. The most common incidents identified by the trigger tool were falls without injury, medication management incidents, and moderate pain. Common contributing factors included delayed, erroneous, or incomplete nursing care and treatment.

SB 3380. 116th Congress (2020).

This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Scott J, Heavey E, Waring J, et al. BMJ Open. 2016;6:e011222.
Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.
Carthon MB, Lasater KB, Sloane DM, et al. BMJ Qual Saf. 2015;24:255-263.
Hospital readmissions are an increasing focus of patient safety efforts, due to Medicare's payment policy. This cross-sectional study sought to assess the link between working environments for nurses and readmissions. Suboptimal working conditions for nurses have been associated with poor patient outcomes. One proposed mechanism to explain this relationship is missed nursing care. Researchers found that hospitals with worse ratings of nurses' work environment and more frequent reports of missed care also had higher readmissions for heart failure. Although this study does not ascertain whether the working conditions or missed care caused the readmissions, the authors suggest that prospective studies looking at missed nursing care and subsequent readmissions are warranted. A recent AHRQ WebM&M perspective discusses the nursing workforce and patient safety.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
London, UK: Parliamentary and Health Service Ombudsman; June 2014.
This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.
Johnston M, Arora S, Anderson O, et al. Ann Surg. 2015;261:831-838.
In most training settings, the first physician point-of-contact for a patient with clinical deterioration is a junior doctor who must evaluate the situation and decide whether to alert a supervising physician—a process termed escalation of care. Delays in this process can lead to critical failure-to-rescue events, which may result in preventable deaths. This study used ethnographic observations, a risk assessment survey, and a formal health care failure mode and effect and analysis to examine the escalation of care process on surgical wards at three London hospitals. The investigation uncovered 18 hazardous failures, with multiple underlying root causes, including outdated communication technology, insufficient staffing, and challenges related to hierarchy. An extensive list of recommendations to improve these processes is included. A prior AHRQ WebM&M commentary discussed some of the pitfalls of hierarchy and the "surgical personality."
An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-36.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.
Lipczak H, Knudsen JL, Nissen A. BMJ Qual Saf. 2011;20:1052-6.
A comprehensive view of patient safety hazards requires identifying safety issues through multiple data sources. This Danish study analyzed safety problems in oncology care through voluntary error reports, retrospective chart review using the Global Trigger Tool, and patient reports. While each data source revealed unique hazards, common problems in this patient population included treatment-related harm (from chemotherapy and other procedures), health care–associated infections, and problems related to communication between providers. An AHRQ WebM&M commentary discusses a preventable complication in a patient receiving outpatient chemotherapy.
Landro L. Wall Street Journal. March 28, 2011.
This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.

Baker GR, ed. Healthc Q. 2010;13(Spec No):1-136.  

This is the fifth in a series of special issues devoted to exploring Canadian patient safety organizational and strategic improvement efforts. The articles highlight work related to topics including critical occurrence review, hand hygiene compliance, and effective handoffs.
Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:658-61.
Implementation of structured processes improved emergency department communication in two areas: communication between paramedics and emergency department staff, and documentation of the patient's initial clinical condition by physicians.