A Roadmap to Advance Patient Safety in Ambulatory Care

Abstract

Advances in patient safety in the past 2 decades have focused mainly on inpatient settings, whereas outpatient settings have been relatively overlooked. However, accumulated evidence leaves little justification to continue neglecting ambulatory safety. 1 A systematic review from 2015 estimated that safety incidents, such as those related to administrative and communication issues, missed or delayed diagnoses, and prescribing and medication management errors, occur in median of 2 to 3incidentsper100primarycarevisits. 2 Otherstudieshave estimated that 5% of US adult outpatients may have experienced a diagnostic error annually 3 and that a projected 4.5 million ambulatory care visits annually in the US may have been related to an adverse drug event. 4 Although errors in ambulatory settings are less likely to lead to immediate harm than errors in acute/inpatient care, their health consequences may be significant nonetheless (eg, from missed cancer diagnosis). Recognizing the need to address outpatient safety, reports from national and international groups have offered an impetus to measure ambulatory patient harm, prioritize nearterm goals, and create high-profile initiatives similar to those for inpatient settings. 1 Several barriers limit progress toward next steps. Care fragmentation and inadequate data systems make it difficult to map longitudinal patient experience in and across multiple settings (eg, primary/specialty care, patient home, diagnostic testing, community-pharmacy), hindering detection and assessment of safety problems. Consider a patient who, after visiting primary care and multiple specialty care settings, 2 laboratories, an imaging center, and an ambulatory surgery center, is diagnosed with lung cancer 1 year after initially presenting with fatigue and weight loss. Identifying this event and then determining sources of diagnostic delay in this patient's clinical course is a challenging task, even if medical records from each setting are easily accessible. Resources, infrastructure for measurement and analytics, and accreditation requirements for safety are less developed for ambulatory settings compared with inpatient settings. Additionally, patients can have complex presentations that include undifferentiated symptoms, multiple chronic conditions, and social needs that warrant attention in time-pressured, information-poor work environments.While the limitations of existing measurement methods have made it difficult to precisely quantify the overall prevalence of harm, evidence suggests that medication errors, diagnostic errors, and communication and coordination breakdowns are the most common causes of preventable harm among outpatients. The scope and consequences of harm include physical, psychological, and financial harms to patients, caregivers, health care workers, and society. A roadmap of milestones is needed to accelerate progress (eFigure in the Supplement).

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices

“…Given the complexity of general practice, estimating diagnostic errors in primary care is challenging. 26 GPs are often tasked with identifying patients with a serious disease from large numbers who present with common symptoms and mostly benign non-urgent diseases, many of which evolve over time. 27 A significant proportion of face-to-face consultations are for reasons other than making a diagnosis.…”

The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety

“…Ambulatory patient safety incidents are frequent, with an estimated 2–3 adverse events in every 100 primary care visits. 1 In an AHRQ (Agency for Healthcare Research and Quality)-commissioned technical brief on ambulatory safety, key informants identified six domains of ambulatory safety (medication management, diagnostic errors, care transitions, referrals, culture, and testing) and six strategies used to address these vulnerabilities (communication, health technology, teams, patient engagement, organizational approaches, and measurement). 2 We use this framework to identify the strategies most altered by telemedicine and how those changes impact specific ambulatory safety domains.…”

A shadowing program for PAs and APRNs to promote collaborative care

“…16 Despite this push for interprofessional education for competency development and increased collaboration among healthcare disciplines, adoption into practice has been slow and inconsistent. 4,17 In higher education, for T he US healthcare system often provides medically complex patients with suboptimal, fragmented care, and a system change to resolve this inadequacy is imperative. [1][2][3] Interprofessional collaboration, in which clinicians from different fi elds work in a unifi ed manner, is an integral component to delivering effi cient, high-quality care, and there is a national push for increased collaborative care in healthcare systems.…”

“…Despite this push for interprofessional education for competency development and increased collaboration among healthcare disciplines, adoption into practice has been slow and inconsistent 4,17. In higher education, for example, significant workload and suboptimal understanding of the role of other healthcare professionals have been shown to impede the implementation of interprofessional education 18.…”