Ambulatory Care Safety

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 original Chronic 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

Specific types of errors can be linked to each of these three concepts.

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 often suboptimal. Poorly handled care transitions (e.g., when a patient is discharged from the hospital or when care is transferred 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, particularly medication 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.

Low and marginally literate patients have difficulty following the prescription label instruction take two tablets by mouth daily even when they are able to read dosage instructions correctly. Of those with low literacy, 70.7% could read label instructions correctly, and 34.7% could demonstrate label instructions correctly. Of those with marginal literacy, 84.1% could read label instructions correctly, and 62.8% could demonstrate label instructions correctly. Of those with adequate literacy, 89.4% could read label instructions correctly, and 80.2% could demonstrate label instructions correctly.

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 AHRQ Medical Office Survey on Patient Safety Culture is designed to assess safety culture in ambulatory care, and its comparative database (which includes data from more than 900 participating practices) is freely available from AHRQ.

Categories of missing clinical information during primary care visits: lab results (45%), letters/dictation (39.5%), radiology results (28.2%), history and physical exam (26.8%), current and prior medications (23.3%), pathology results (15%), immunization records (12.3%), procedures (7.3%).

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

Although efforts to improve safety have largely focused on hospital care, The Joint Commission now publishes National Patient Safety Goals focused on ambulatory care. The Agency for Healthcare Research and Quality is also leading efforts to improve ambulatory quality and safety through programs and research funding. A 2016 systematic reviewcommissioned by the World Health Organization identified missed and delayed diagnoses and medication errors as the chief safety priorities in ambulatory care, and it highlighted the need to develop clear and consistent definitions for patient safety incidents in primary care