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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. 

Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers.

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.

Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Grossman E, Phillips RS, Weingart SN. J Patient Saf. 2010;6:172-179.
Tests pending after hospital discharge or following a clinic visit continue to challenge most health care systems. This study implemented a paper-based system to follow up abnormal mammograms and monitored provider responses to those reminders. Based on a report of abnormal mammograms generated by the radiology department, a practice administrator sent a letter to each provider with a copy of the report and a set of questions on behalf of their quality improvement committee. More than 90% of providers responded to the fail-safe reminders, 8% were unaware of the abnormal test, and there was no follow-up plan in place for 3% of cases. Less experienced providers were more likely to be unaware of abnormal mammograms and many lapses were noted in the context of care transitions. The authors conclude that their paper-based system is feasible and valuable but requires full engagement of providers in the process.
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.

Baker GR, ed. Healthc Q. 2009;12(Spec No Patient):1-198.  

This special issue discusses Canadian patient safety efforts in identifying risks, designing safe systems, implementing solutions, developing learning systems, and understanding legal decision making.
Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-9.
Failure to adequately follow up on test results is a known problem after hospital discharge, in primary care settings, and within computerized systems. This study reviewed more than 5400 patient medical records from 19 community-based and 4 academic primary care practices and discovered a 7.1% rate of failure to inform (or document informing). Interestingly, investigators found that partial electronic health records (EHRs), with a mix of paper and electronic systems, were associated with higher failure rates than those practices without an EHR or with a complete EHR. Variations in failure rates among practices, ranging from 0% to 26%, suggest that best practices can make a significant difference. A past AHRQ WebM&M commentary discussed the impact of delayed notification for a test result following hospital discharge.
Lo HG, Matheny ME, Seger DL, et al. J Am Med Inform Assoc. 2009;16:66-71.
"Alert fatigue" refers to the tendency of clinicians to ignore safety alerts—for example, warnings about potential drug interactions—if alerts are too frequent or perceived to be clinically irrelevant. However, in this study, less intrusive alerts that did not require physician response were not effective at encouraging use of recommended laboratory monitoring.
Moore C, Saigh O, Trikha A, et al. J Patient Saf. 2008;4:241-244.
Physicians reported dissatisfaction with their ability to follow up on test results in a timely fashion, with resident physicians frequently reporting an inability to check test results in less than 1 week. The need for standardized methods for following up test results in ambulatory care was noted in a prior study.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.