It’s not only an inpatient issue
“In recent years, much attention has been focused on improving patient safety in hospitals,” Jack Ende, MD, MACP, president, ACP, was quoted as saying. “We now must extend that focus to include the ambulatory setting. Medical errors that happen outside of the hospital are just as important to prevent.”
The paper outlines the following seven principles and recommendations aimed at improving patient care in office-based practices.:
A culture of safety
Physicians and healthcare organizations have a responsibility to promote a culture of patient safety within their practices and among colleagues with whom they collaborate.
- Patient safety goals must be embedded in the daily activity of the healthcare team and office staff.
- Medical error reporting efforts should encourage accuracy, confidentiality, and compliance, and ensure that information is useful, actionable, and non-punitive, and is focused on actual events and near-misses.
- A culture of safety can be encouraged by adopting liability protections that protect physicians and the healthcare team from being penalized for reporting errors and working with patients to address safety issues.
A 2012 survey found that nearly half of U.S. physicians surveyed experience at least one symptom of burnout, and the prevalence of burnout is higher among physicians than other workers. General internal medicine physicians and other front-line physicians were among specialties reporting the highest amounts of burnout. Subsequent surveys indicate that the problem is worsening.
Rick factors for burnout among healthcare providers include time pressure, lack of control over work processes, role conflict, and poor relationships between groups and with leadership, combined with personal predisposing factors and the emotional intensity of clinical work. Additional factors include the following:
- Health information technology. Concerns have been raised about the association between electronic medical records (EMRs) and higher stress levels, less job satisfaction, and increased time pressure among primary care physicians.
- Alert fatigue due to the barrage of information delivered through computerized order entry systems, EMRs, and other avenues may cause clinicians to tune out and become desensitized to information, potentially raising the risk for an adverse event.
- Error incident reporting can pose an administrative burden, discouraging clinicians from reporting less severe mistakes.
Recommendations to reduce burnout include:
- Workflow redesign, such as changing call schedules and assigning certain tasks to nurses or medical assistants.
- Improved communication among clinicians and staff, including teamwork building and monthly clinician meetings to enhance collegiality.
- Quality improvement projects directed at clinician concerns, such as more automated prescription phone lines and medication reconciliation projects.
Patient and family education
Patient and family education, engagement, and health literacy efforts are needed to educate the public about asking the right questions and providing the necessary information to their physician or other healthcare professional. Materials should reflect the linguistic and cultural characteristics of the audience.
Communication breakdowns between clinicians and patients may threaten patient safety. Use of medical jargon, health illiteracy, and limited understanding of information can increase the risk. Further, patient confusion can lead to medication adherence problems that lead to adverse drug events. Evidence shows that patient engagement is associated with fewer inpatient adverse events and can instigate best practices, such as high hand-washing rates among clinicians.
The Institute of Medicine has stressed the importance of patient-clinician engagement in improving diagnosis, points out the ACP. Healthcare professionals and organizations should create an environment that is conducive to patient engagement, making electronic health records and diagnostic testing results accessible to patients, and identifying opportunities to include patients and families in efforts to learn from diagnostic errors and near-misses.
Needed: Patient safety metrics
ACP supports the continued research into and development of a comprehensive collection of standardized patient safety metrics and strategies, with particular attention to primary care and other ambulatory settings. Domains could include medication safety, diagnosis, transitions, referrals, and testing issues. ACP recommends expanded patient safety research efforts to better understand ambulatory medical errors and the efficacy of patient safety practices.
Most patient safety measures have been focused on the inpatient setting and initiatives, such as value-based purchasing and hospital-acquired-conditions penalties, ACP points out. In fact, of the 22 patient safety measures endorsed by NQF in 2016, only four were related to the ambulatory setting. If ambulatory care patient safety is going to improve, errors will have to be reported and compared with patient safety targets to help understand the epidemiology of errors and spur better outcomes.
But developing process and outcomes measures for outpatient safety won’t be easy. Patients are cared for by multiple clinicians in multiple settings, complicating coordination of care assessment, and real-time tracking of outpatient safety events is more difficult to achieve than in the inpatient setting. Also of concern is the issue of proper attribution, to ensure physicians and other healthcare professionals are not blamed for errors outside of their control.
Team-based care models, such as the patient-centered medical home, should be encouraged and optimized to improve patient safety and facilitate communication, cooperation, and information-sharing among team members. Evidence suggests that healthcare delivery system models that encourage better communication and collaboration among clinicians may be associated with safety improvements.
An efficient, interoperable health IT system can facilitate healthcare team communication, efficient workflow, and delivery of educational prompts that improve timeliness and accuracy of diagnoses, and enhance care transitions and referrals. Health IT can also facilitate patient-clinician communication outside of the office setting in ways that mitigate the potential for errors and improve patient self-management.
Computerized provider order entry systems have been shown to reduce medication errors, and have been widely adopted in the hospital and outpatient setting following implementation of the federal HITECH Act and Meaningful Use program. Technologies, such as text-based and pager alerts, computerized decision-support systems, and decision-support algorithms, may help reduce diagnostic errors
A national safety agency
A national effort to prevent patient harm across the healthcare sector should be established. A national entity could be charged with coordinating and collaborating with stakeholders, defining the problem, setting national goals, and developing and assisting in the implementation of a patient safety action plan with attention given to the ambulatory setting.
In its “Free from Harm” report, the National Patient Safety Foundation calls for the creation of a centralized agency to coordinate patient safety efforts. Such a body would function similar to the Federal Aviation Administration or the Nuclear Regulatory Commission, and would coordinate efforts, facilitate communication among stakeholders, provide direction, ensure accountability and disseminate best practices.
ACP believes that establishing a regulatory agency would elevate the issue, broaden the focus from single patient safety initiatives, and help to break down silos that act as a barrier to system-wide patient safety improvement.
Source: Patient Safety in the Office-Based Practice Setting, American College of Physicians: A Position Paper, 2017, https://www.acponline.org/acp_policy/policies/patient_safety_in_the_office_based_practice_setting_2017.pdf
Diagnostic errors are the most common type of error that occurs in the ambulatory setting, says the American College of Physicians in “Patient Safety in the Office-Based Practice Setting, American College of Physicians: A Position Paper, 2017.” Although definitions and terminology for diagnostic errors vary, the Institute of Medicine has developed a patient-centered definition of diagnostic error: “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.”
According to the IOM, at least 5 percent of all U.S. adults who receive outpatient care each year will experience a diagnostic error, and most people will likely experience a meaningful diagnostic error in their lifetime. A population-based study estimated that the rate of outpatient diagnostic errors is 5.08 percent, or about 12 million U.S. adults every year. The IOM estimated that 10 percent of patient deaths are attributable to diagnostic errors and found that most paid malpractice claims for the outpatient setting were attributable to diagnostic errors.
A 2017 study conducted by the Mayo Clinic found that 21 percent of patients who had received a second opinion regarding a diagnosis had their original diagnosis completely changed, and 66 percent of patients saw their original diagnosis better defined or redefined. Only 12 percent of original diagnoses were complete and correct. In a 2006 review of paid malpractice claims for diagnosis errors that resulted in adverse outcomes, 59 percent were associated with a major or significant physical adverse outcome and 30 percent were associated with death.
The diagnoses missed were cancer (59 percent, with 24 percent involving breast cancer), infections (5 percent), fractures (4 percent), and myocardial infarctions (4 percent). Eighty-five percent of errors occurred in physicians’ offices. A 2013 study used electronic medical record triggers to detect primary care diagnostic errors and found that pneumonia, decompensated congestive heart failure, and cancer were the most common diagnoses missed.