Why It Matters
Three interrelated challenges in patient safety — diagnostic error, ambulatory care, and health information technology — require seeing the big patient safety picture.
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The Urgency of 3 Intersecting Patient Safety Challenges

By Tejal Gandhi | Thursday, March 22, 2018
Urgency of 3 Intersecting Patient Safety Challenges

Each year, I am fortunate to meet many committed, curious health professionals in my work. Occasionally, someone will ask if I ever get discouraged by the pace of progress in patient safety. After all, we’ve been at this for a long time, yet the scope of the problem sometimes seems as vast as ever.

I’d like to see greater progress, of course, yet I truly believe that care is safer now than it was 20 years ago, thanks to greater awareness, research, education, development, and implementation of best practices. That said, as medicine, health care, and technology evolve, we need to continually assess new challenges and create new approaches. We need to maintain a sense of urgency and innovation, because the costs are too high for patients to do anything less.

Consider three big, interrelated challenges in patient safety: diagnostic error, ambulatory patient safety, and health information technology. Each of these intersects and overlaps with the others, offering lessons in why looking at the big patient safety picture is necessary to progress in targeted areas.

Diagnostic Error

Diagnostic error has been in the news recently, labeled number one in a top ten list of patient safety concerns and a chief cause of medical malpractice cases in another assessment. Almost three years after the National Academy of Medicine issued a consensus report outlining the scope of diagnostic error and recommendations for improvement, today’s news may seem like we are taking one step forward, two steps back.

In fact, this sense of alarm is a positive sign that people and organizations are working on improving diagnostic error and helping to raise awareness of the implications, from the standpoint of both cost to the health care system and harm to patients.

Diagnostic error is a particularly thorny challenge in that there are often multiple contributing factors — systems factors as well as cognitive. Yet many health professionals and researchers are putting innovative theories into action, including testing patient-centric models of primary care that extend the responsibility for diagnosis beyond the primary care clinician to include nurses, pathologists, radiologists, and others.

Health IT has great potential to help improve diagnosis through predictive analytics. In a recent study, researchers analyzed records of 190,000 patients admitted to the hospital following a stroke. They linked missed opportunities for earlier diagnosis in patients who were previously evaluated in outpatient settings for complaints of dizziness or vertigo.

But the questions around improving diagnostic error require multiple answers — and health IT innovations are only one piece of the puzzle.

Safety in Ambulatory Settings

Although diagnostic errors can happen in any setting, they are a major concern in ambulatory settings, which are almost uncharted territory when it comes to patient safety.

In a recent technical brief about the state of patient safety activity in ambulatory care, the Agency for Healthcare Research and Quality (AHRQ) found that while ambulatory settings have some safety risks in common with hospitals, “. . . the ambulatory environment has many distinct safety issues, most notably medication safety, safety culture, transitions among providers in ambulatory settings, and timely and accurate diagnosis, which includes issues arising from referrals from one provider to another, and management of test results.”

In the interest of full disclosure, I was among the patient safety “key informants” who were interviewed as part of the information-gathering process for this work. I was not surprised that the authors found that little research has been done to evaluate the effectiveness of hospital-based patient safety best practices in ambulatory settings.

That said, many quality and safety professionals are testing and implementing initiatives to improve patient identification in ambulatory settings, improve patient safety for those receiving care at home, and engage patients and their families to achieve safer care in primary settings.

Health Information Technology

As noted above, health IT can help improve big concerns like ambulatory safety and diagnostic error, for example, by enabling more reliable systems for tracking referrals and following up on consultations, lab results, and imaging. Like diagnostic error, however, optimal use of health IT requires close attention to both the systems issues involved and the human factors and workflow issues.

Before the most promising health IT functionality can become widespread, we need more universal improvements in functions like decision support, team-based clinical documentation, patient portals, and optimizing workflow in primary care, where technology is often seen as a contributor to burnout.

Learn, Lead, and Help Spread Progress

These three broad challenges intersect and overlap with each other, as do many patient safety issues currently being addressed in silos. The IHI patient safety team has been advocating for a total systems approach to safety — where safety is at the core of health care delivery across the continuum and a primary focus of any new initiative. Creating such approaches will require innovative thinking and contributions from all stakeholders.

Ultimately, I am optimistic about the future, because innovation is happening everywhere. We need to embrace every opportunity to learn it, lead it, or help it spread. And despite our successes, we should never lose a sense of urgency when it comes to improving patient safety.

Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer.

Editor’s note: Diagnostic error, ambulatory patient safety, and innovations in health information technology are among the session topics and tracks at the IHI/NPSF Patient Safety Congress, May 23-25, 2018, in Boston, Massachusetts.

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