Spotlight shifts to outpatient safety

It may be a bigger challenge to prevent errors in the ambulatory setting than in hospitals.

By Kevin B. O’Reilly — Posted June 12, 2006

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Missing lab results. Illegible prescriptions. Patients who don't understand doctors' instructions. Referrals that are not pursued. Medical errors in the outpatient setting might not receive as much attention as wrong-site surgeries or hospital-acquired infections, but they are just as real and can cause more harm in the aggregate, according to patient-safety experts at the eighth annual National Patient Safety Foundation's Patient Safety Congress last month.

"Errors are pervasive" in ambulatory care, said Terry Hammons, MD, senior vice president of research and information for the Medical Group Management Assn. "Ambulatory care is logistically complex. There are lots of missed connections."

Looking beyond hospitals

Robert M. Wachter, MD, chief of the medical service at the University of California, San Francisco, who for years has studied patient safety in hospitals, agreed. "We have hit the point where we need to turn our attention to ambulatory care. It has been stuffed to the bottom of the deck so readily because it's so complicated."

While important efforts such as the Institute for Healthcare Improvement's Campaign to Save 100,000 Lives have successfully focused on reducing ventilator-associated pneumonia and central-line infections in hospitals, the problem of how to improve in the outpatient setting where "the patient is a moving target" is underappreciated, Dr. Wachter said.

"Ambulatory care is less consequential per error, but when it's added up, it may cause more harm in the end," he said.

While primary-care physicians make up only one-fourth of all physicians, they account for half of all care provided, according to Richard G. Roberts, MD, professor of family medicine at the University of Wisconsin School of Medicine and Public Health.

"When we have bad things happen in hospitals, it's often because an error in primary care landed [the patient] there," Dr. Roberts said.

One in seven primary-care visits includes a medical error of some kind, according to Dr. Roberts' summary of recent research, with 24% of those errors resulting in harm and 70% having the potential to cause harm. Stress and fatigue are contributing factors. Forty-eight percent of family and internal medicine physicians surveyed by the Agency for Healthcare Research and Quality researchers said their practice was chaotic. Sixty-one percent said they were stressed out, and more than a quarter said they were burned out.

Only as good as the data

While many tout information technology as a cure-all to the problem, numerous experts cited a March 2005 Journal of the American Medical Association study of computerized physician order entry at a large hospital showing that incomplete data and poor implementation can create new and unintended problems.

"IT is a tool, not a solution," said Carolyn M. Clancy, MD, AHRQ director, adding that ambulatory safety and medication safety in particular will be a "huge focus" for the agency this year.

"Improvement in ICUs has really been phenomenal," Dr. Clancy said. "But when we start moving out of fixed institutions, the question gets more complicated.

"The sickest people are seeing 12 to 14 doctors. We would like to do all we can to keep people out of the ICU to begin with."

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System breakdowns

Risk management and safety experts at Kaiser Permanentediscovered that in 44% of the 8.4 million-member plan's sentinel events, demands for payment and liability lawsuits grew out of diagnosis-related delays and failures. Top culprits:

55% Failure to order appropriate diagnostic or lab tests

44% Inappropriate or inadequate follow-up

38% Incorrect interpretation of diagnostic or lab tests

31% Inadequate physical conducted

26% Inadequate patient history taken

26% Failure to make a referral

17% Patient's failure to comply with follow-up

9% Ordered lab or test not performed

9% Ordered lab or test performed incorrectly

Source: Doug Bonacum and Mark Littlewood, "Reliability -- Being Sure That the Dots are Connected and No One Drops the Ball in Diagnostic Studies and Referrals," presented May 11 at the National Patient Safety Congress

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