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This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

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.
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
Kutikov A, Weinberg DS, Edelman MJ, et al. Ann Intern Med. 2020;172:756-758.
Oncology patients, as with other patients with chronic health care needs, face numerous challenges during the COVID-19 pandemic. The authors discuss the need to balance delays in cancer diagnosis or treatment against the harm of COVID-19 exposure, how to mitigate the risk for significant care disruptions associated with social distancing and managing the allocation of limited healthcare resources during this unprecedented pandemic.
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
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.
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.
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.
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.

Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.
Rattray NA, Sico JJ, Cox LAM, et al. Jt Comm J Qual Patient Saf. 2017;43:127-137.
Communication between inpatient clinicians and primary care physicians at the time of hospital discharge is often suboptimal, and it may not have improved with the advent of electronic health records. This qualitative study examined barriers to inpatient–outpatient communication in the care of stroke patients and found that clear communication is needed to ensure effective handoffs.
Price EL, Sewell JL, Chen AH, et al. Jt Comm J Qual Patient Saf. 2016;42:341-54.
Outpatient practices are increasingly using electronic referrals, or eConsults, to obtain clinical input from specialists because of insufficient access to subspecialty care. In an eConsult, the referring clinician (usually a primary care physician) will provide clinical information to the specialist via email or a web-based system. The specialist will review the information in the electronic medical record and decide whether further testing, treatment, or an in-person consultation is necessary. This retrospective study evaluated the safety of the electronic referral process by reviewing the medical records of patients who had been referred to a gastroenterology clinic and were not scheduled for in-person appointments. Investigators sought to determine the number of patients deemed not to require appointments and how many remained unscheduled. Emergency care or hospitalization for the referral complaint was rare overall; however, among patients whose electronic referrals remained unresolved (when investigators could find no decision regarding need for in-person visit and symptoms prompting referral were not addressed in the medical record), more than 70% were at moderate to high risk of potential harm. These cases included many patients who had no documented health care visits in the 6 months after the electronic referral was placed. Although the authors did not identify any definitive cases of harm attributable to failures of the electronic referral process, this study does highlight the need for robust tracking of eConsults to ensure appropriate follow-up by referring providers.
Gardner LA. PA-PSRS Patient Saf Advis. 2016;13:58-65.
Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Jackson PD, Biggins MS, Cowan L, et al. Rehabil Nurs. 2016;41:135-48.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.