Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

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. 

Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.

Most patient interactions with the health care system occur in the outpatient setting. Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and practice do not seem to have reached deeply into ambulatory care.

Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...