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Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

This commentary discusses challenges for patient safety improvement work in the ambulatory setting along with recommendations for addressing them.

This AHRQ-funded study describes one organization’s efforts to detail its preoperative process around care transitions in order to highlight obstacles and areas for intervention.