Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.

Care integration —the linking of care across primary, secondary, social, community, and mental health—can improve care for patients with chronic conditions. In this review, 24 studies of integrated care were included. Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home or across settings (e.g., hospital and primary care). The authors recommend future research focus on safety targets beyond falls and medication safety and report on outcomes.

Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.

Improving care transitions is a patient safety priority. Based on interviews with 21 nurses in Sweden, this study explored nursing concerns regarding transitions of care from inpatient to home healthcare settings in rural areas. Participants cited concerns regarding care coordination, communication, and logistics.

Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.

Implicit biases and stigma can negatively impact health care provided to patients with substance use disorders such as alcohol use disorder (AUD). This narrative review concluded that patients with AUD are frequently undiagnosed and not appropriately referred for treatment or treated. The authors cite barriers to effective care for patients with AUD, including poor integration and coordination between medical care and behavioral health care in the United States.

Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.

Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.

Lack of timely follow-up of test results is an ongoing patient safety problem in primary care and can lead to missed or delayed diagnoses. This systematic review concluded that follow-up of abnormal mammograms in primary care is suboptimal. Findings from included studies indicate that ethnic minorities and women with lower educational attainment were more likely to have inadequate follow-up. Factors influencing follow-up include physician-patient miscommunication, alert fatigue, difficulty obtaining test results or patient records, and logistical barriers. The authors suggest adopting interventions focused on mitigating factors that negatively impact follow-up, such as patient navigation and case management.

Resolving medication errors often requires coordination between different care providers. This qualitative study examined medication safety incidents at one VA hospital and found that health care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents. The primary barriers to care coordination identified were role ambiguity, breakdowns in care, and electronic health record-related challenges.

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.

Optimal use of health information exchange approaches such as event notification systems may be influenced by organizational capabilities. This study found that healthcare organizations whose positive perceptions of event alerts fit within existing workflows were more likely to use event notification services to improve care coordination and care quality.

Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.

Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.

This study used qualitative methods to compare how patients versus front clinicians, administrators and staff conceptualize patient safety in primary care. Findings indicate that work function-based conceptualizations of patient safety (e.g., good communication and providing appropriate, timely care) better reflect the experiences of healthcare personnel and patients rather than domain-based conceptualizations (e.g., diagnosis, care transitions, and medications).

This study surveyed 9,206 adults across the United States about their perceptions of medical errors occurring in ambulatory care settings. Thirty-six percent of respondents perceived that their doctor has ever made a mistake, provided an incorrect diagnosis, or given an incorrect (or delayed) treatment. According to these findings, patient-perceived medical errors and harms occurred most commonly in women and those in poor health with comorbid conditions.  

The authors used qualitative data to evaluate parental perspectives of quality in pediatric home-based hospice and palliative care (HBHPC) programs, and how parents define “safe care” in the home. Thematic analysis identified eight domains of safety prioritized by patients, including an emphasis on the safety of the physical environment, medication safety, maintaining comfort and preventing harm, and trust in the HBHPC caregivers.

This study used national survey data to examine avoidance of healthcare services among transgender, gender nonconforming, and non-binary people. Researchers found that nearly one quarter of respondents reported not seeking healthcare when necessary because they anticipated being disrespected or mistreated by healthcare professionals. Previous experience with certain discriminatory behavior such as invasive questions, refusal of care, verbal harassment, as well as cost and needing to educate providers, were strong predictors of healthcare avoidance.