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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. 

Watson J, Salisbury C, Whiting PF, et al. Br J Gen Pract. 2022;Epub Jun 6.
Failure to communicate blood test results to patients may result in delayed diagnosis or treatment. In this study, UK primary care patients and general practitioners (GPs) were asked about their experiences with the communication of blood test results. Patients and GPs both expected the other to follow up on results and had conflicting experiences with the method of communication (e.g., phone call, text message).

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.

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.

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.
Emani S, Sequist TD, Lacson R, et al. Jt Comm J Qual Patient Saf. 2019;45:552-557.
Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.
Olmstead J. Nurs Manage. 2019;50:8-10.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
Tully AP, Hammond DA, Li C, et al. Crit Care Med. 2019;47:543-549.
Transitions of care, whether from the hospital to the outpatient setting or within the hospital itself, represent a vulnerable time for patients. Inadequate communication during handoffs that occur as part of care transitions can contribute to adverse events and errors, including medication errors. This study of 58 intensive care units (ICUs) across 34 United States hospitals and 2 Dutch hospitals sought to assess medication errors among patients transferred from ICUs. Of the 985 patients included in the study, almost half (46%) experienced a medication error during transition out of the ICU. Discontinuing orders and reordering medications at the time of transfer out of the ICU as well as daily patient rounding in the ICU were associated with decreased odds of medication error during transition. A past Annual Perspective discussed challenges associated with handoffs and transitions of care.
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.
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.
A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.
Litchfield I, Bentham L, Lilford R, et al. BMJ Qual Saf. 2015;24:691-9.
Failure to appropriately communicate test results is a recognized safety hazard in ambulatory care. Despite more than a decade of research into this problem, this survey of 50 general practices in the United Kingdom found that 80% required patients to call to find out their test results, and a similar proportion had no fail-safe mechanism for tracking test results.
After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. J Patient Saf. 2014;10:29-44.
This direct observation study found that registered nurses, physicians, and nursing aides have frequent interruptions and limited time for shift-change handoffs. This finding suggests that widespread efforts to ensure adequate handoff time and minimize interruptions have not mitigated these problems in hospital settings.
DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-10.
Reviewing evidence on transitions in care, this article describes how one university health system developed a comprehensive handoff curriculum to address educational needs in the context of changes to resident duty hours.
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.