Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.  

Routine depression screening by primary care providers is recommended to decrease risk of suicide and self-harm. Using unannounced standardized patient visits, researchers were able to compare depression screening rates before and after intervention (including personalized provider feedback). Depression screenings were completed more frequently up to one-year postintervention.

Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.

Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.

Failure to follow-up on test results in ambulatory practice is a common, serious safety concern. This study examined the use of a results manager tool by primary care physicians in Partners Healthcare in Boston. Although the vast majority of providers used the tool, many did not find that it was helpful for any specific purpose and only 64% were satisfied with the tool.

Highlighting how the disconnect between hospital medicine programs and primary care practices introduces challenges to ensuring continuity of care and information transfer, this commentary relates strategies for strengthening communication and partnership between hospitalists and primary care providers to augment these handoffs.

This ethnographic case study explored patient handoffs across different situations, including pre-hospital and primary care settings. These analyses emphasize numerous contextual issues that need be considered when creating computerized systems to support handoffs.

Although electronic test ordering resulted in fewer patient identification errors in a clinical laboratory, significant variability in error rates between centers remained, emphasizing the continued effect of human behavior on interventions.

Appropriate follow-up of abnormal test results remains a difficult issue. This local task force report recommends standardization of notification policies, clear identification of the care team, enhanced electronic result tracking, and quality reporting and metrics.

Failure to properly follow up on test results can result in missed or delayed diagnoses. This study from the Veterans Affairs (VA) system reveals the clinical impact of inadequate care processes for patients with urgent follow-up needs. By analyzing 111 root cause analyses of diagnostic error cases in the outpatient setting, the authors determined that poorly coordinated care—arising from a lack of systems to track patients needing urgent evaluation, insufficient follow-up of abnormal test results, and inadequate communication between clinicians—contributed to most of the missed or delayed diagnoses. Although electronic medical records (EMRs) should facilitate responding to abnormal test results, prior VA studies have shown that a small but clinically significant proportion of abnormal laboratory tests and radiology studies are not acted upon in a timely fashion (despite the VA having a fully integrated EMR for more than a decade). The authors advocate for refining EMR systems to better facilitate communication between clinicians and for emphasizing teamwork training in the outpatient setting.