Patient Safety in Ambulatory Care
Background
Despite the fact that the vast majority of health care takes place in the outpatient, or ambulatory care, setting, efforts to improve safety have mostly focused on the inpatient setting. However, a body of research dedicated to patient safety in ambulatory care has emerged over the past few years. These efforts have identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety.
Factors Influencing Safety in Ambulatory Care
Ensuring patient safety outside of the hospital setting poses unique challenges for both providers and patients. A recent article proposed a model for patient safety in chronic disease management, modified from the originalChronic Care Model. This model broadly encompasses three concepts that influence safety in ambulatory care:
Types of Safety Events in Ambulatory Care
Since face-to-face interactions between providers and patients in the ambulatory setting are limited and occur weeks to months apart, patients must assume a much greater role in and responsibility for managing their own health. This elevates the importance of including the patient as a partner and ensuring that patients understand their illnesses and treatments. The need for outpatients to self-manage their own chronic diseases requires that they monitor their symptoms and, in some cases, adjust their own lifestyle or medications. For example, a patient with diabetes must measure her own blood sugars and perhaps adjust her insulin dose based on blood sugar values and dietary intake. A patient's inability or failure to perform such activities may compromise safety in the short term and clinical outcomes in the long term. Patients must also understand how and when to contact their caregivers outside of routine appointments, and they must often play a role in ensuring their own care coordination (e.g., by keeping an updated list of medications).
The nature of interactions between patients and providers—and between different providers—may also be a source of adverse events. Patients consistently voice concerns about coordination of care, particularly when one patient sees multiple physicians, and indeed communication between physicians in the outpatient setting is oftensuboptimal. Poorly handled care transitions (e.g., when a patient is discharged from the hospital or when care istransferred from one physician to another) also place patients at high risk for preventable adverse events. When a clinician is not immediately available—for example, after hours—patients may have to rely on telephone advice for acute illnesses, an everyday practice that has its own inherent risks.
Underlying health system flaws have been documented to increase the risk for medical errors, particularlymedication errors and diagnostic errors, issues that are certainly germane to ambulatory safety. Medication errors are very common in ambulatory care, with one landmark study finding that more than 4.5 million ambulatory care visits occur every year due to adverse drug events. Likewise, prescribing errors are startlingly common in ambulatory practice. Because the likelihood of a medication error is linked to a patient's understanding of the indication, dosage schedule, proper administration, and potential adverse effects, low health literacy and poor patient education contribute to elevated error risk.
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Source: Wolf MS, Davis TC, Shrank W, et al. To err is human: Patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 2007;67:293-300. [go to PubMed]
The fragmentation of ambulatory care in outpatient settings increases the challenge of making a timely and accurate diagnosis. Indeed, a recent study estimated that 5% of adults in the United States experience a missed or delayed diagnosis each year. Recent data suggests that timely information availability and managing test results contribute to delayed and missed diagnoses in outpatient care. Although use of electronic health records in the ambulatory setting is growing, many practices still lack reliable systems for following up on test results—a problem that has been implicated in missed and delayed diagnoses.
Finally, while an increasing amount of attention has been devoted to measuring and improving the culture of safety in acute care settings, less is known about safety culture in office practice. Burnout and work dissatisfaction, particularly among primary care physicians, may adversely affect the quality of care. The AHRQMedical Office Survey on Patient Safety Culture is designed to assess safety culture in ambulatory care, and itscomparative database (which includes data from more than 900 participating practices) is freely available from AHRQ.
Source: Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;293:565-571. [go to PubMed]
Improving Safety in Ambulatory Care
Improving outpatient safety will require both structural reform of office practice functions as well as engagement of patients in their own safety. While EHRs hold great promise for reducing medication errors and tracking test results, these systems have yet to reach their full potential. Coordinating care between different physicians remains a significant challenge, especially if the doctors do not work in the same office or share the same medical record system. Efforts are being made to increase use of EHRs in ambulatory care, and physicians believe that use of EHRs leads to higher quality and improved safety.
Patient engagement in outpatient safety involves two related concepts: first, educating patients about their illnesses and medications, using methods that require patients to demonstrate understanding (such as "teach-back"); and second, empowering patients and caregivers to act as a safety "double-check" by providing access to advice and test results and encouraging patients to ask questions about their care. Success has been achieved in this area for patients taking high-risk medications, even in patients with low health literacy at baseline.
Current Context
Regulatory efforts to improve safety have largely focused on hospital care; in fact, 12 of the 16 Joint CommissionNational Patient Safety Goals are considered "not applicable to ambulatory care." It seems likely that the increased attention to ambulatory safety being evidenced in increased research funding and output will be reflected in growing attention by accreditors and regulators in the not too distant future.
Despite the fact that the vast majority of health care takes place in the outpatient, or ambulatory care, setting, efforts to improve safety have mostly focused on the inpatient setting. However, a body of research dedicated to patient safety in ambulatory care has emerged over the past few years. These efforts have identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety.
Factors Influencing Safety in Ambulatory Care
Ensuring patient safety outside of the hospital setting poses unique challenges for both providers and patients. A recent article proposed a model for patient safety in chronic disease management, modified from the originalChronic Care Model. This model broadly encompasses three concepts that influence safety in ambulatory care:
- The role of patient and caregiver behaviors
- The role of provider–patient interactions
- The role of the community and health system
Types of Safety Events in Ambulatory Care
Since face-to-face interactions between providers and patients in the ambulatory setting are limited and occur weeks to months apart, patients must assume a much greater role in and responsibility for managing their own health. This elevates the importance of including the patient as a partner and ensuring that patients understand their illnesses and treatments. The need for outpatients to self-manage their own chronic diseases requires that they monitor their symptoms and, in some cases, adjust their own lifestyle or medications. For example, a patient with diabetes must measure her own blood sugars and perhaps adjust her insulin dose based on blood sugar values and dietary intake. A patient's inability or failure to perform such activities may compromise safety in the short term and clinical outcomes in the long term. Patients must also understand how and when to contact their caregivers outside of routine appointments, and they must often play a role in ensuring their own care coordination (e.g., by keeping an updated list of medications).
The nature of interactions between patients and providers—and between different providers—may also be a source of adverse events. Patients consistently voice concerns about coordination of care, particularly when one patient sees multiple physicians, and indeed communication between physicians in the outpatient setting is oftensuboptimal. Poorly handled care transitions (e.g., when a patient is discharged from the hospital or when care istransferred from one physician to another) also place patients at high risk for preventable adverse events. When a clinician is not immediately available—for example, after hours—patients may have to rely on telephone advice for acute illnesses, an everyday practice that has its own inherent risks.
Underlying health system flaws have been documented to increase the risk for medical errors, particularlymedication errors and diagnostic errors, issues that are certainly germane to ambulatory safety. Medication errors are very common in ambulatory care, with one landmark study finding that more than 4.5 million ambulatory care visits occur every year due to adverse drug events. Likewise, prescribing errors are startlingly common in ambulatory practice. Because the likelihood of a medication error is linked to a patient's understanding of the indication, dosage schedule, proper administration, and potential adverse effects, low health literacy and poor patient education contribute to elevated error risk.
Source: Wolf MS, Davis TC, Shrank W, et al. To err is human: Patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 2007;67:293-300. [go to PubMed]
The fragmentation of ambulatory care in outpatient settings increases the challenge of making a timely and accurate diagnosis. Indeed, a recent study estimated that 5% of adults in the United States experience a missed or delayed diagnosis each year. Recent data suggests that timely information availability and managing test results contribute to delayed and missed diagnoses in outpatient care. Although use of electronic health records in the ambulatory setting is growing, many practices still lack reliable systems for following up on test results—a problem that has been implicated in missed and delayed diagnoses.
Finally, while an increasing amount of attention has been devoted to measuring and improving the culture of safety in acute care settings, less is known about safety culture in office practice. Burnout and work dissatisfaction, particularly among primary care physicians, may adversely affect the quality of care. The AHRQMedical Office Survey on Patient Safety Culture is designed to assess safety culture in ambulatory care, and itscomparative database (which includes data from more than 900 participating practices) is freely available from AHRQ.
Source: Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;293:565-571. [go to PubMed]
Improving Safety in Ambulatory Care
Improving outpatient safety will require both structural reform of office practice functions as well as engagement of patients in their own safety. While EHRs hold great promise for reducing medication errors and tracking test results, these systems have yet to reach their full potential. Coordinating care between different physicians remains a significant challenge, especially if the doctors do not work in the same office or share the same medical record system. Efforts are being made to increase use of EHRs in ambulatory care, and physicians believe that use of EHRs leads to higher quality and improved safety.
Patient engagement in outpatient safety involves two related concepts: first, educating patients about their illnesses and medications, using methods that require patients to demonstrate understanding (such as "teach-back"); and second, empowering patients and caregivers to act as a safety "double-check" by providing access to advice and test results and encouraging patients to ask questions about their care. Success has been achieved in this area for patients taking high-risk medications, even in patients with low health literacy at baseline.
Current Context
Regulatory efforts to improve safety have largely focused on hospital care; in fact, 12 of the 16 Joint CommissionNational Patient Safety Goals are considered "not applicable to ambulatory care." It seems likely that the increased attention to ambulatory safety being evidenced in increased research funding and output will be reflected in growing attention by accreditors and regulators in the not too distant future.
What's New in Patient Safety in Ambulatory Care on AHRQ PSNet
GRANT ANNOUNCEMENT
AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).
US Department of Health and Human Services; February 13, 2015. Program Announcement No. RFA-HS-15-002.
REVIEW
Safety of medication use in primary care.
Olaniyan JO, Ghaleb M, Dhillon S, Robinson P. Int J Pharm Pract. 2015;23:3-20.
PRESS RELEASE/ANNOUNCEMENT
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Settings.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. February 10, 2015. Publication No. NOT-HS-15-006.
NEWSPAPER/MAGAZINE ARTICLE
Once easily recognized, signs of measles now elude young doctors.
Brown E, Lin RG II R, Xia R. Los Angeles Times. January 26, 2015.
STUDY
Lack of timely follow-up of abnormal imaging results and radiologists' recommendations.
Al-Mutairi A, Meyer AND, Chang P, Singh H. J Am Coll Radiol. 2015 Jan 9; [Epub ahead of print].
STUDY
Doctors' experiences of adverse events in secondary care: the professional and personal impact.
Harrison R, Lawton R, Stewart K. Clin Med. 2014;14:585-590.
STUDY
Patient safety skills in primary care: a national survey of GP educators.
Ahmed M, Arora S, McKay J, et al. BMC Fam Pract. 2014;15:206.
AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).
US Department of Health and Human Services; February 13, 2015. Program Announcement No. RFA-HS-15-002.
Safety of medication use in primary care.
Olaniyan JO, Ghaleb M, Dhillon S, Robinson P. Int J Pharm Pract. 2015;23:3-20.
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Settings.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. February 10, 2015. Publication No. NOT-HS-15-006.
Once easily recognized, signs of measles now elude young doctors.
Brown E, Lin RG II R, Xia R. Los Angeles Times. January 26, 2015.
Lack of timely follow-up of abnormal imaging results and radiologists' recommendations.
Al-Mutairi A, Meyer AND, Chang P, Singh H. J Am Coll Radiol. 2015 Jan 9; [Epub ahead of print].
Doctors' experiences of adverse events in secondary care: the professional and personal impact.
Harrison R, Lawton R, Stewart K. Clin Med. 2014;14:585-590.
Patient safety skills in primary care: a national survey of GP educators.
Ahmed M, Arora S, McKay J, et al. BMC Fam Pract. 2014;15:206.
A "Reflexive" Diagnosis in Primary Care.
John Betjemann, MD, and S. Andrew Josephson, MD. AHRQ WebM&M [serial online]. April 2014
No News May Not Be Good News.
Carlton R. Moore, MD, MS. AHRQ WebM&M [serial online]. August 2012
Patient Safety: A Perspective from Office Practice.
Richard J. Baron, MD. AHRQ WebM&M [serial online]. May 2009
The Role of Health Literacy in Patient Safety.
Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH. AHRQ WebM&M [serial online]. February/March 2009
In Conversation with...Dean Schillinger, MD.
AHRQ WebM&M [serial online]. February/March 2009
Patient Safety in the Physician Office Setting.
Nancy C. Elder, MD, MSPH. AHRQ WebM&M [serial online]. May 2006
John Betjemann, MD, and S. Andrew Josephson, MD. AHRQ WebM&M [serial online]. April 2014
Carlton R. Moore, MD, MS. AHRQ WebM&M [serial online]. August 2012
Richard J. Baron, MD. AHRQ WebM&M [serial online]. May 2009
Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH. AHRQ WebM&M [serial online]. February/March 2009
AHRQ WebM&M [serial online]. February/March 2009
Nancy C. Elder, MD, MSPH. AHRQ WebM&M [serial online]. May 2006
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. Report No. 14-0032-EF.
Turney S, Evans EW, Callaway E, et al. Englewood Cliffs, CO: Medical Group Management Association; 2009.
Kaiser Family Foundation, Agency for Healthcare Research and Quality; October 2008.
Failure to follow-up test results for ambulatory patients: a systematic review.Callen JL, Westbrook JI, Georgiou A, Li J. J Gen Intern Med. 2012;27:1334-1348.
Adverse drug events in U.S. adult ambulatory medical care.Sarkar U, López A, Maselli JH, Gonzales R. Health Serv Res. 2011;46:1517-1533.
Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.
Refocusing the lens: patient safety in ambulatory chronic disease care.Sarkar U, Wachter RM, Schroeder SA, Schillinger D. Jt Comm J Qual Patient Saf. 2009;35:377-383.
Information exchange among physicians caring for the same patient in the community.van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-1018.
Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version.Modak I, Sexton JB, Lux TR, Helmreich RL, Thomas EJ. J Gen Intern Med. 2007;22:1-5.
Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.
Adverse drug events in ambulatory care.Gandhi TK, Weingart SN, Borus J, et al. N Engl J Med. 2003;348:1556-1564.
Oakbrook Terrace, IL: The Joint Commission; 2015.
Rockville, MD: Agency for Healthcare Research and Quality; July 2014.
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