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 the community and health system
• The role of provider-patient interactions
• The role of patient and caregiver behaviors

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

Types of Safety Events in Ambulatory Care

Finally, although 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 also 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.

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]

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 (for example, 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.

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 patient education and ensuring that patients understand their illnesses and treatments. 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 ADEs. Because the likelihood of a medication error is linked to a patient's understanding of the indication, dosage schedule, proper administration, and potential side effects, low health literacy and poor patient education contribute to increased 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]

Finally, 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 diabetic patient 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 must often play a role in ensuring their own care coordination (for example, by keeping an updated list of medications).

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 Commission National 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.