Patient Safety Gaps in Rheumatology: A Mixed-Methods Study

Objectives: To identify facilitators and barriers to implementing patient safety measures in rheumatology practice by integrating national performance data with the Consolidated Framework for Implementation Research (CFIR)-guided interviews. Findings will yield practical, actionable recommendations to improve implementation and reduce preventable gaps in patient safety across US rheumatology practices. Methods: We conducted an explanatory mixed-methods study using data from the American College of Rheumatology’s (ACR) Rheumatology Informatics System for Effectiveness (RISE) registry and semistructured interviews with practice personnel, guided by CFIR. Practice-level performance on patient safety measures was quantified, and RISE practices were purposively sampled across performance strata for interviews. Supplemental interviews were conducted at academic medical centers (AMCs) and Veterans Affairs (VA) sites not represented in RISE. Between June and December 2024, we interviewed 21 participants across 19 rheumatology practices regarding clinical workflows, barriers, facilitators, and opportunities for improvement related to medication safety. Transcripts were thematically analyzed using both CFIR-based deductive and inductive coding. Results: The study included 11 RISE community practices, 5 AMCs, and 3 VA practices. Implementation of safety measures was shaped by workflow design, staffing, organizational support, and electronic health record (EHR) functionality. Facilitators included previsit chart review, protocolized workflows, pharmacist involvement, EHR alerts, automated dose calculations, and performance feedback. Barriers included limited access to external test results, unstructured documentation, manual data entry, workload pressures, and incomplete patient testing. Conclusions: Reliable implementation of rheumatology safety measures depends on strong workflows, team-based accountability, and robust data infrastructure. Improving safety will require investment in structured documentation, interoperable EHR tools, and systems to support patient follow-up.