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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.  

Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.

The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.

Point-of-care test results are often manually transcribed into the electronic health record, which introduces risks of manual transcription errors. The authors of this study took advantage of a redundant workflow in which point-of-care blood glucose results were uploaded and also manually entered by staff. They estimate that 5 in 1000 manually entered results contain clinically significant transcription errors and call for interfacing point-to-care instruments as a patient safety strategy.

Implementation of the electronic health record has led to providers engaging in workarounds to circumvent system limitations. This survey found that nearly half of providers at Veterans Affairs medical centers use workarounds when managing test results in the electronic health record. The authors suggest that results management should be improved in future electronic health records and work systems to enhance efficiency and care coordination.

Quality cancer care is often threatened by poor communication and lack of coordination. Prior research has described cancer patients' perspectives related to communication breakdowns, but this study used focus groups with primary care physicians, oncologists, and nurses to explore the clinician viewpoint. Many insightful quotes are included throughout the article illustrating complex interchanges between patients, providers, and health systems in the high-stakes arena of longitudinal cancer care. One highlighted problem related to some patients' reticence to discuss adverse effects of therapy due to fear that they will no longer be offered further treatments. Clinicians often found it challenging to balance hope with reality and to provide accurate information to patients and their families. They also expressed frustration with systems factors, such as appointments that are too short for having serious in-depth conversations. The authors suggest a number of potential solutions for facilitating open communication between patients and providers.

In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.

This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.

Electronic health records have had mixed effects on patient safety. This qualitative study of physicians and nurses revealed safety concerns about alert fatigue and propagation of incorrect information as well as perceived safety improvements through enhanced communication and legibility.

In this study, primary care providers frequently relied on extraordinary actions to overcome system barriers in obtaining their patients' timely and safe cancer evaluations. This finding provides evidence that downstream measures, such as timeliness of diagnosis, may fail to detect major system problems.

Despite the well-documented prevalence of adverse events after hospital discharge and a growing policy focus on preventing readmissions, the factors leading to poor care transitions are not well understood. This qualitative study from Spain used in-depth interviews with patients, hospital staff, and primary care providers to better define the mechanisms by which adverse events and readmissions occur. The investigators found that discharge processes are often haphazard and a major source of frustration for hospital providers, and that patients often shoulder the burden of communicating clinical information to their primary care providers, which leaves those with limited health literacy particularly vulnerable to errors. These findings mirror and expand upon prior research. This study is part of a large, multi-national effort to improve the quality of patient handovers.

Although much has previously been written about inpatient signout communication, this qualitative study is one of few to explore handoffs of multidisciplinary providers in the outpatient setting.