Looking beyond the hospital for patient safety

The past decade has seen a surge of interest in patient safety issues affecting hospital inpatients, spurred in large part by a landmark Institute of Medicine report in 1999 that reported the widespread occurrence of preventable medical errors each year in U.S. hospitals.

Since that IOM study, public policymakers, patient advocacy groups and others have been clamoring for more attention to be paid to the all-too-often deadly problem of inpatient medical errors. Increased research funds in this area -- undoubtedly a good response to such a crisis -- have followed.

But every physician knows that the need to be vigilant about protecting every patient's life and well-being doesn't end at the hospital's sliding doors. After all, there are about 300 patient visits conducted in ambulatory care settings for every one hospital admission. Medical errors can and do happen in physician offices, ambulatory surgery centers, skilled nursing facilities and other places where patients receive outpatient care.

Patient safety experts convened by the American Medical Association Center for Patient Safety reviewed roughly 100 studies from 2000 to 2010 that have investigated outpatient safety. In the group's December 2011 report, one of the key conclusions was that such research unnecessarily has taken a back seat over the past decade to research conducted on hospital-based problems.

The ambulatory care studies that have been undertaken give some invaluable insight into safety issues faced in those settings. They document disturbing instances of safety problems, including serious mistakes in diagnosis, prescribing and communication. But although it is clear that these issues are widespread, the body of research does not identify which problems are the most harmful -- and thus deserving not only of additional research, but of extensive corrective action.

Public reports about inpatient hospital errors often focus on the seemingly most egregious cases, such as a doctor operating on the wrong patient or removing the wrong body part. But an office-based physician who does not order the correct medication, fails to follow up on a test result or has insufficient communication with a referring doctor can cause just as much harm to a patient, if not more. Errors of omission can be just as bad as errors of commission, even if they are harder to spot.

The primary barrier in the way of safety improvement is not a lack of will by physicians to do better. If studies can pinpoint the most harmful ambulatory safety issues and give a tangible sense of the scope of the problems, corrective plans with achievable goals can be crafted for everyone to follow. Outpatient safety improvement efforts could be linked with and complemented by inpatient initiatives that already are in place to help prevent hospital readmissions.

Until real data and real solutions are made available, however, the unacceptable status quo will persist despite physicians' best efforts. Especially in this case, knowledge is power.

That's why the AMA report calls for much more robust safety research in the ambulatory care setting. Implementation of the health system reform law will mean an increased focus on using outpatient care to keep patients out of the hospital in the first place, making such a revision in research priorities all the more vital.

Such a systemic shift is not going to be quick and easy, but it is possible. Physicians are committed to their patients no matter where they treat them, and with some more information and guidance, patient safety can become the name of the game in every care setting.