Sixteen years ago, the Institute of Medicine's landmark report To Err Is Human generated widespread attention for its estimate that as many as 98,000 deaths occur annually from preventable medical errors in U.S. hospitals.
More recent research suggests that number could be as high as 440,000. That would make it the third-leading cause of death in the nation—after heart disease and cancer.
What's even more stunning is that those estimates are only for errors in hospitals, and most healthcare is delivered outside of hospital settings. Roughly 1 billion ambulatory visits occur annually in the U.S., compared with 35 million hospital admissions.
Yet most patient safety research has focused on inpatient settings. Far less has addressed care provided in physician offices; community pharmacies; clinics; ambulatory surgical, medical and imaging centers; and long-term, hospice and home-care settings, among others.
The need to address patient safety in all settings is one of the recommendations contained in Free from Harm, a report published in December by the National Patient Safety Foundation. According to the studies cited, more than half of annual paid medical malpractice claims were for events in the outpatient setting, and two-thirds involved major injury or death. About one-third of Medicare beneficiaries in skilled-nursing facilities experienced an adverse event, and half of those were deemed preventable.
The challenge lies in the care provided in each of the settings across the continuum as well as in the transfer of patients from one setting to another.
According to a 2003 study in the Annals of Internal Medicine, handoffs and care transitions set up a high risk for adverse events. Half of all medication errors occur at interfaces of care, according to a study done at Mayo Health System's Luther Midelfort Hospital in Eau Claire, Wis. And 41% of patients had test results come back after their discharge, with doctors unaware of two-thirds of the results, according to a 2005 study in the Annals of Internal Medicine. Also, 28% of discharges included recommendations for outpatient workups, yet within six months of discharge, more than a third were not completed, according to a 2007 study in the Archives of Internal Medicine.
Not surprisingly, patients are aware of mistakes in ambulatory care. One study showed that 15% of primary-care patients reported that a physician had made a mistake; 13% reported a wrong diagnosis; 13% reported a wrong treatment; and 14% changed physicians because of a mistake.
What are we to do? There needs to be a seamless flow of medical information between settings. Targeted interventions in the discharge process and post-discharge period have great potential. Electronic prescribing with decision support has high potential for reducing serious medication errors. The failure of healthcare providers to follow up with patients must be addressed.
In addition, Free from Harm recommends these actions:
Key to improving patient safety across the care continuum is creating a culture of safety. As Free from Harm states, “A strong safety culture is one in which healthcare professionals and leaders are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before they harm patients, and strong feedback loops enable frontline staff to learn from previous errors and alter care processes to prevent recurrences.” The report underscores that “high-reliability organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives.”
Patient safety is essential to the delivery of healthcare no matter where it's provided, and outpatient settings will be providing more and more care. As technology increases the types and amounts of care provided outside the hospital, the entire care continuum must become the focus for patient safety. That's where the future of patient safety lies, and where far too many preventable dangers exist.
