Patient Safety

Improving patient safety is a critical issue for health care systems, and although strides have been made in recognizing and preventing adverse events much remains to be done to make health care safe and reliable. In particular, patient safety in outpatient settings remains understudied, especially given the majority of health care occurs in ambulatory settings. Our laboratory uses implementation science and systems engineering methodologies to improve outpatient safety locally and across the state.

Visual abstract of retrospective cohort study assessing adherence to follow-up guidelines for incidental pulmonary nodules


Agency for Healthcare Research and Quality (AHRQ) P30 grant: Building an Ambulatory Patient Safety Learning Laboratory for Diverse Populations: The San Francisco Ambulatory Safety Center for iNnovaTion (ASCENT)

Agency for Healthcare Research and Quality (AHRQ) R01 grant: Investigating Failures of Notification and Monitoring in Outpatient Care: the Safety Promotion Action Research and Knowledge (SPARK) Network

Gordon and Betty Moore Foundation grant: Provider Engagement and Excellence in Reviewing Diagnosis (PEER-Dx)

Selected Publications

  1. Patterson ES, Su G, Sarkar U. Reducing delays to diagnosis in ambulatory care settings: A macrocognition perspective. Appl Ergon. 2019 Oct 9;82:102965. doi: 10.1016/j.apergo.2019.102965.

  2. Fontil V, Lyles CR, Schillinger D, Handley MA, Ackerman S, Gourley G, Bibbins-Domingo K, Sarkar U. Safety-net institutions in the US grapple with new cholesterol treatment guidelines: a qualitative analysis from the PHoENIX Network. Risk Manag Healthc Policy. 2018; 11:99-108. PMID: 30034258.

  3. Khoong EC, Cherian R, Smith DE, Schillinger D, Wolf MS, Sarkar U. Implementation of patient-centered prescription labeling in a safety-net ambulatory care network. Am J Health Syst Pharm. 2018 Jun 27. PMID: 29950392.

  4. Ratanawongsa N, Quan J, Handley MA, Sarkar U, Schillinger D. Language-concordant automated telephone queries to assess medication adherence in a diverse population: a cross-sectional analysis of convergent validity with pharmacy claims. BMC Health Serv Res. 2018 Apr 06; 18(1):254. PMID: 29625571.

  5. Ackerman SL, Gourley G, Le G, Williams P, Yazdany J, Sarkar U. Improving Patient Safety in Public Hospitals: Developing Standard Measures to Track Medical Errors and Process Breakdowns. J Patient Saf. 2018 Mar 14. PMID: 29543667.

  6. Sarkar U, McDonald K, Motala A, Smith P, Zipperer L, Wachter RM, Shanman R, Shekelle PG. Pragmatic Insights on Patient Safety Priorities and Intervention Strategies in Ambulatory Settings. Jt Comm J Qual Patient Saf. 2017 Dec; 43(12):661-670. PMID: 29173287.

  7. Clarity C, Sarkar U, Lee J, Handley MA, Goldman LE. Clinician Perspectives on the Management of Abnormal Subcritical Tests in an Urban Academic Safety-Net Health Care System. Jt Comm J Qual Patient Saf. 2017 Oct; 43(10):517-523. PMID: 28942776.

  8. Handley MA, Quan J, Chao MT, Ratanawongsa N, Sarkar U, Emmons-Bell S, Schillinger D. Use of Complementary Health Approaches Among Diverse Primary Care Patients with Type 2 Diabetes and Association with Cardiometabolic Outcomes: From the SF Bay Collaborative Research Network (SF Bay CRN). J Am Board Fam Med. 2017 Sep-Oct; 30(5):624-631. PMID: 28923815.

  9. Hemmat S, Schillinger D, Lyles C, Ackerman S, Gourley G, Vittinghoff E, Handley M, Sarkar U. Performance Measurement and Target-Setting in California's Safety Net Health Systems. Am J Med Qual. 2018 Mar/Apr; 33(2):132-139. PMID: 28555507.

  10. Lyles C, Sarkar U. Seeing the Effect of Health Care Delivery Innovation in the Safety Net. JAMA Intern Med. 2017 May 01; 177(5):649-650. PMID: 28346579.

  11. Issaka RB, Singh MH, Oshima SM, Laleau VJ, Rachocki CD, Chen EH, Day LW, Sarkar U, Somsouk M. Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System. Am J Gastroenterol. 2017 Feb; 112(2):375-382. PMID: 28154400.

  12. Sarkar U, Lyles C, Steinman M, Huang ES, Moffet HH, Whitmer RA, Warton EM, Karter AJ. Changes in Medication Use After Dementia Diagnosis in an Observational Cohort of Individuals with Diabetes Mellitus. J Am Geriatr Soc. 2017 Jan; 65(1):77-82. PMID: 27642180.

  13. Gertler SA, Coralic Z, López A, Stein JC, Sarkar U. Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department. J Patient Saf. 2016 09; 12(3):119-24. PMID: 24583958.

  14. Horton C, Sarkar U, Fernandez A.Medical Management of Vulnerable and Underserved Patient: Principles, Practice, and Populations. Applying Principles and Practices of Quality Improvement for Better Care of the Underserved. 2016; 193-203.

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