Narrow Results Clear All
- Communication Improvement 31
- Culture of Safety 17
- Education and Training 22
- Error Reporting and Analysis 26
- Human Factors Engineering 10
- Legal and Policy Approaches 9
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 26
- Research Directions 4
- Specialization of Care 3
- Teamwork 4
- Technologic Approaches 17
- Transparency and Accountability 1
- Device-related Complications 1
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 13
- Drug shortages 2
- Identification Errors 2
- Interruptions and distractions 2
- Medical Complications 10
- Medication Safety 29
- Nonsurgical Procedural Complications 3
- Overtreatment 1
- Psychological and Social Complications 1
- Surgical Complications 3
- Internal Medicine 20
- Primary Care 28
- Surgery 2
- Nursing 2
- Pharmacy 13
- Family Members and Caregivers 2
- Health Care Executives and Administrators 60
Health Care Providers
- Nurses 1
- Physicians 12
- Non-Health Care Professionals 33
- Patients 6
- Australia and New Zealand 2
- Europe 14
- Canada 3
Search results for "Ambulatory Care"
- Ambulatory Care
Sokol PE, Wynia MK; AMA Expert Panel on Care Transitions. Chicago, IL: American Medical Association; February 2013.
This report proposes five responsibilities for ambulatory care practices to ensure safe care transitions and describes principles to guide staff in performing these tasks.
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. AHRQ Publication No. 19-0033.
The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.
Brownlee S, Garber J. Brookline, MA: Lown Institute; 2019.
Overprescribing is a common problem that contributes to patient harm. This report examines financial, clinical, and societal trends of medication overuse and inappropriate polypharmacy in older Americans. A culture of prescribing, deficits in information and knowledge, and fragmented care contribute to the problem. The report provides interventions to improve the safety of prescribing, including developing deprescribing guidelines, raising awareness among providers and patients about medication overload, and implementing team-based care models.
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.
Boston, MA: Institute for Healthcare Improvement; 2019.
Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Lim R, Semple S, Ellett LK, Roughead L. Canberra, Australia: Pharmaceutical Society of Australia; 2019.
Analyzing the evidence on medication errors in Australia, this report estimates the incidence of acute care admissions, emergency department use, ambulatory adverse events, and elderly patients affected by medication-related problems. Pharmacists are emphasized as pivotal to medication safety improvement efforts.
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
Boston, MA: Institute for Healthcare Improvement; 2018.
The home care setting harbors unique challenges to patient safety. This report builds on a previous evidence assessment to provide recommendations to improve the safety of home-based care. The document outlines five guiding principles to enhance safety of home care, which include a focus on person-centered care, safety culture, learning and improvement systems, team-based and coordinated care provision, and incentive models.
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF.
A vibrant culture of safety is critical to achieving high reliability in health care. Organizations with stronger safety culture boast lower in-hospital mortality and fewer surgical site infections. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2018 comparative database report assessed 10 safety culture domains in nearly 2500 ambulatory care practices. Respondents reported high rates of teamwork and strong systems for patient follow-up. Many practices identified productivity pressures and work pace as safety hazards. Although the practices surveyed are not nationally representative, they do allow leaders and scientists to compare safety culture across practices and time. A past WebM&M commentary examined safety hazards associated with productivity pressures in health care.
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and Development; 2018.
The global economic impact of medical error is substantial. This report expands on a 2017 analysis to address a gap in understanding about the impact of medical mistakes in ambulatory and primary care environments across 29 countries. The authors found iatrogenic harm and associated disease burden in outpatient care to be concerning and suggest the need for policy and leadership to design and implement improvement strategies.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Dallas, TX: Facilities Guidelines Institute; 2018.
These updated guidelines include design changes, such as the adoption of private rooms to reduce medical error, interruptions, and hospital-acquired infections. The 2018 edition was developed as a 3-volume set covering hospitals, outpatient facilities, and residential health, care, and support facilities. Each provides information on design elements that enhance safety. The material also includes risk assessments to identify space concerns that could lead to unsafe conditions.
Davis K, Collier S, Situ J, Coe M, Cleary-Fishman M. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.
Philadelphia, PA: American College of Physicians; 2017.
Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. This position paper highlights seven recommendations to address patient safety challenges in the ambulatory environment, including enhancing patient health literacy, utilizing team-based care models, and establishing a national effort to reduce patient harm across all settings of health care.
Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017.
Patient perspectives have been shown to identify otherwise undetected adverse events. This Institute for Healthcare Improvement–National Patient Safety Foundation commissioned survey, an update to their original 1997 survey, interviewed a probability-based sample of 2536 American adults. The results demonstrate the widespread nature of patient safety problems. Overall, 20% of respondents reported personally experiencing a medical error, most often in the outpatient setting. However, only 10% of respondents said they experienced harm when receiving medical care, which underscores the contrast between error and harm. The most common type of error was a missed or delayed diagnosis, followed by a communication error. About a third of errors were not reported. These results highlight the need to focus on diagnostic safety in the outpatient setting in order to improve patient safety in United States health care.
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
Incorporating patient safety in education and learning environments can augment physician engagement in quality and safety work. This publication outlines how organizations can enable new clinicians to develop a long-term patient safety focus through leadership involvement in safety culture and an infrastructure that supports reporting, transparency, and measuring improvements.
Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017.
Morbidity and mortality from opioid medications constitutes a patient safety problem. This National Academy of Medicine report explores the role of physicians in preventing and treating opioid misuse. The report highlights the increasing rate of opioid prescriptions in parallel with rising numbers of opioid overdose deaths and recommends adherence to clinical guidelines on opioid use, specifically the 2016 CDC guideline. The authors call for improved access to opioid prescription and dispensing data and more stringent regulation of opioid medications. They provide detailed recommendations for clinicians to prescribe opioids more safely, including the use of prescription drug monitoring programs, coprescription of naloxone, and engaging with community resources to identify and treat opioid use disorder. A recent PSNet perspective discussed opioid overdoses as a patient safety problem.