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Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18:40-45.
Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.   
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
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.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Ai A, Desai S, Shellman A, et al. Jt Comm J Qual Patient Saf. 2018;44:674-682.
This study examined ambulatory follow-up of test results by aggregating multiple types of data—national surveys on safety culture and patient satisfaction; patient complaints; safety reports; and electronic health record audits of provider response times. Researchers found an association between quicker response time for test results and higher patient satisfaction. They conclude that merging these disparate data sources can uncover new levers to improve patient safety.
Arbaje AI, Hughes A, Werner N, et al. BMJ Qual Saf. 2019;28:111-120.
Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.
Grant S, Guthrie B. Soc Sci Med. 2018;203:43-50.
Past studies have explored the impact of nurse and clinician workload on the quality of care. In this study, researchers examined how general practitioners and administrative staff across eight United Kingdom practices work together to fill prescription requests and manage test results.
Grant S, Checkland K, Bowie P, et al. Implement Sci. 2017;12:56.
Test result management is a critical aspect of ambulatory patient safety. This direct observation study identified highly variable strategies across outpatient practices with different vulnerabilities. These results underscore the need to develop interventions to enhance management of test results.
Gardner LA. PA-PSRS Patient Saf Advis. 2016;13:58-65.
Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Gillies D, Chicop D, O'Halloran P. Crisis. 2015;36:316-324.
This study used root cause analysis to identify underlying causes of suicide among mental health service clients. Researchers found that most patients had denied suicidal ideation and had missed follow-up in their mental health care. Their results underscore the challenge of preventing suicide in patients with mental illness.
Bowie P, Halley L, McKay J. BMJ Open. 2014;4:e004245.
In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.
Chui MA, Stone JA. Res Social Adm Pharm. 2014;10:195-203.
This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.
Giardina TD, King BJ, Ignaczak AP, et al. Health Aff (Millwood). 2013;32:1368-75.
Failure to properly follow up on test results can result in missed or delayed diagnoses. This study from the Veterans Affairs (VA) system reveals the clinical impact of inadequate care processes for patients with urgent follow-up needs. By analyzing 111 root cause analyses of diagnostic error cases in the outpatient setting, the authors determined that poorly coordinated care—arising from a lack of systems to track patients needing urgent evaluation, insufficient follow-up of abnormal test results, and inadequate communication between clinicians—contributed to most of the missed or delayed diagnoses. Although electronic medical records (EMRs) should facilitate responding to abnormal test results, prior VA studies have shown that a small but clinically significant proportion of abnormal laboratory tests and radiology studies are not acted upon in a timely fashion (despite the VA having a fully integrated EMR for more than a decade). The authors advocate for refining EMR systems to better facilitate communication between clinicians and for emphasizing teamwork training in the outpatient setting.
Smith MW, Giardina TD, Murphy DR, et al. BMJ Qual Saf. 2013;22:1006-13.
In this study, primary care providers frequently relied on extraordinary actions to overcome system barriers in obtaining their patients' timely and safe cancer evaluations. This finding provides evidence that downstream measures, such as timeliness of diagnosis, may fail to detect major system problems.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.