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Much of the harm that occurs in outpatient settings is preventable.
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Meeting the Unique Challenges of Patient Safety Beyond the Hospital

By Tejal Gandhi | Tuesday, March 5, 2019

As the nation — and many of my IHI colleagues — recover from seasonal colds and flu, I’m reminded of the observation that we are “a nation of patients.” Nearly 85 percent of us visited a physician’s office over the past year. And office visits, of course, are only a subset of outpatient care. When we consider ambulatory surgery centers, urgent care clinics, and emergency departments, it’s easy to see how outpatient care far exceeds the volume of care provided in hospitals.

We also know that some of the most familiar risks of health-care-related harm — like medication errors, missed and delayed diagnosis, and faulty transitions in care — are just the tip of the iceberg in ambulatory settings.

Perhaps more important, research suggests that much of the harm that occurs relative to outpatient care is preventable. A recent report from the Organisation for Economic Co-operation and Development found that the number of patients experiencing harm in ambulatory settings is 20 percent in developed countries and 25 percent in developing countries, and that up to 80 percent of harm in these settings is preventable.

How to tackle these issues? To begin, it’s important to have a grasp of the many ways in which outpatient care differs from hospital care:

  • Long feedback loops — Unlike inpatient care, which is provided 24/7 during a patient’s stay, outpatient care is episodic. Unless there is strong communication, clinicians may not know what’s going on with patients when they are out in the world. We’re seeing some improvement in this area in the use of patient portals, continuous monitoring, and telemedicine, which allow for greater engagement by patients and greater monitoring ability in between visits. Making this work, however, requires team-based care and coordination to stay on top of events that happen between visits. At the same time, the options for more continuous engagement puts added responsibility on patients and caregivers, and the impact of that needs to be understood.
  • Low signal-to-noise ratio — I’m specifically thinking of the diagnostic challenges involved in primary care. Did the patient with a headache you saw this morning have a migraine? A sinus infection? Or an intracranial bleed? Over the course of a few months, a PCP may see dozens of patients with chest pain, but only a tiny fraction of these are having a heart attack. This is vastly different than inpatient care. To be sure, diagnoses can still be missed or delayed in inpatient care, but the resources and ready availability of tests makes it less likely that a major issue will go unnoticed. Much more work needs to be done to understand the cognitive challenges faced by clinicians in making the right diagnoses, and how to prevent potential cognitive errors.
  • Distributed care — Even today, with consolidation of large health systems, it is not uncommon for patients to have a PCP in one practice, a cardiologist in another, and a gastroenterologist at a third. Some patients get medications from multiple pharmacies. Patients receiving care at home may also be interacting with multiple providers who don’t necessarily talk to one another. Many different players have to be coordinated, and that doesn’t always happen effectively. The push for greater interoperability in health IT systems and greater efforts to close the loop on referrals and test results can lead to progress here. And as with everything related to patient safety, teamwork and communication best practices are key in this setting, and may be more challenging than what has been faced in the inpatient setting.
  • Limited redundancies and greater degrees of freedom — One example of this is medications. During a hospital stay, a patient’s medication is tightly monitored, with multiple steps and checkpoints from prescribing to administering. When patients are on their own, this process looks vastly different. As we are learning in a current project on medication optimization in primary care, there are many other factors to consider when medication is used in the outpatient setting. Does the patient understand why they are being prescribed the medication? Can they afford it? Can they access the medication, and do they take it as prescribed? Does the patient understand side effects and know what to do about them? Does the patient even agree that they need the medication? Achieving medication optimization of will require a much more advanced level of patient-clinician engagement.

Making progress in these areas may be a slow process, but it’s important to continue to build on some of the work already being done. For example, new models of care emphasize working in clinical teams that are better able to respond to patient needs. The Patient-Centered Medical Home model has been shown to reduce costs of care and improve patients’ experience of care, two components of the Triple Aim.

Resources are available to help boost patient and family engagement in primary care. And IHI’s own Framework for Safe, Reliable and Effective Care is helpful in looking at both the big picture of safety and tackling specific initiatives and goals.

We all have a stake in making health care safer. As a patient, what are your chief concerns?

Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer. She will be participating in a Twitter chat on the topic of diagnostic error on March 14 at noon ET. Join with the hashtag #PSAW19.

You may also be interested in:

Patient Safety Awareness Week Free Webcast, March 13, Advancing Patient Safety Beyond the Hospital

IHI Patient Safety Congress (May 15–17, 2019 in Houston, TX, USA)

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