Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
1 - 20 of 57
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.
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.
Dinsdale E, Hannigan A, O'Connor R, et al. Fam Pract. 2019.
Clear communication between primary care physicians and the providers to whom they refer patients has important implications for achieving accurate diagnosis and appropriate treatment plans for patients. In this observational study, researchers included 6603 patients from 68 general medical practices in Ireland, randomly selecting 100 patients from each practice and excluding patients without complete records. They analyzed referral documentation and responses received from subspecialists as well as discharge summaries from hospitalizations over a 2-year period, compared with established national standards. Although 82% of referral letters included current medications, only 30% of response letters and discharge summaries contained medication changes and 33% had medication lists. The authors conclude that significant communication gaps exist between primary and secondary care and that further research is needed to understand how to address them. A past PSNet perspective discussed challenges associated with care transitions.
Given BA. Semin Oncol Nurs. 2019;35:374-379.
Cancer patients often rely on family members or paid caregivers to assist with care maintenance at home, such as taking medications and mobility support. This review highlights common safety gaps in home cancer care. The authors suggest that nurses can help assess caregiver knowledge and provide education to address safety issues.
Butcher L.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Schwarz CM, Hoffmann M, Schwarz P, et al. BMC Health Serv Res. 2019;19:158.
Care transitions represent a vulnerable time for patients, especially at the time of hospital discharge. In this systematic review, researchers identified several factors related to discharge summaries that may adversely impact the safety of discharged patients, including delays in sending discharge summaries to outpatient providers as well as missing or low-quality information.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Huth K, Stack AM, Chi G, et al. Jt Comm J Qual Patient Saf. 2018;44:719-730.
Successful initiatives that have enhanced the safety of handoffs have largely focused on the inpatient setting. This study determined that handoffs between outpatient pediatric providers and the emergency department at a single institution varied in quality, which can lead to unnecessary testing and other harm. A past Annual Perspective discussed how robust handoffs may improve safety outcomes.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2019;28:103-110.
Older adults frequently encounter medication-related harm, which may result in preventable hospitalizations. In six Hawaiian hospitals, hospital pharmacists identified older patients at risk of medication problems and assigned them to a community pharmacist who coordinated their medications across prescribers for 1 year after discharge. This post-hoc analysis of the intervention found that most medication-related harm occurred in the community (70%) rather than the hospital and that the intervention successfully reduced community-acquired harm.
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.
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.
Peeples L.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Sederstrom J.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
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.
Fiscella K, McDaniel SH. Amer Psychol. 2018;73:451-467.
Teamwork is an important element of safe care delivery. This review explores the evidence on the role of teams in ambulatory care, innovations in primary care teamwork models, and barriers to success. The authors offer recommendations to encourage team development in primary care, including defining team competencies, providing team training opportunities specific to ambulatory care, and adjusting care payment mechanisms.
Ackerman SL, Gourley G, Le G, et al. J Patient Saf. 2021;17:e773-e790.
Patients in safety-net health systems may face unique patient safety risks. This study sought to use a consensus approach to develop standard measures for tracking safety gaps in ambulatory care in health systems that primarily serve vulnerable populations. The investigators identified nine measures suitable for tracking two high-priority safety gaps: notifying patients of actionable test results and monitoring patients with high-risk conditions.
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.
Following a positive fecal immunochemical test (a screening test for colon cancer), a colonoscopy was ordered for a 50-year-old man. Two months later, the nurse called him to see if he had obtained the colonoscopy. The patient reported that he was unable to schedule it due to cost of the copayment. The primary physician called the insurance company and was informed that the colonoscopy would be covered in full if the indication was written as preventive rather than diagnostic.
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.