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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. 

Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
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.
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).  
Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.
Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors. 
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Ellis RJ, Schlick CJR, Feinglass J, et al. BMJ Qual Saf. 2020;29:103-112.
This retrospective study of cancer care safety examined the extent to which patients received recommended chemotherapy. A significant proportion of breast, lung, and colorectal cancer patients did not receive chemotherapy; patients who were black and those lacking health insurance or covered by Medicaid were at higher risk. There was marked variability in chemotherapy delivery by location and hospital. The authors conclude that failure to administer chemotherapy is a significant safety gap that should be addressed.
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.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Orenstein EW, Ferro DF, Bonafide CP, et al. JAMIA Open. 2019;2(3):392-398.
Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.
Redmond P, McDowell R, Grimes TC, et al. BMJ Open. 2019;9:e024747.
This retrospective cohort study of patients age 65 and older on chronic medications found that unintentional medication discontinuation does occur following hospitalization. As with prior studies, medication documentation in hospital discharge summaries remains highly variable.
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.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Umberfield E, Ghaferi AA, Krein SL, et al. Jt Comm J Qual Patient Saf. 2019;45:406-413.
Communication failures are a common underlying factor in adverse events. Although the relationship between communication failures and safety has been best studied in the operating room, this issue likely contributes to safety problems in all settings of care. Investigators examined incident reports at an academic medical center to characterize how communication problems contribute to adverse events. Errors of purpose—a type of error in which the goals of the communication event remain unresolved, implying that situational awareness was not achieved—were among the most common types of communication problems identified. The authors point out that while structured communication tools (such as the I-PASS handoff tool) can improve the accuracy and completeness of information transfer, they are not well suited to improving communication in clinically ambiguous situations. Communication problems most often led to delays in care without physical harm, highlighting the difficulty of measuring communication issues compared to other types of safety events. A WebM&M commentary discussed a series of communication errors that led to a child's death.
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.