The point has been well made that while most of the patient safety literature focuses on hospital errors, most healthcare is delivered in office settings. Consider this: for every one hospitalized patient, 28 people visit a physician's office.1 Nevertheless, the early emphasis on patient safety in the hospital was natural: the stakes are higher, errors are more visible, and the resources to research safety problems and implement solutions are all greater there.
The scope of potential errors is also broader in the hospital. Although both settings are beset by medication and laboratory errors, and both inpatient and outpatient errors center on transitions of care and communication problems, the ambulatory setting will see fewer surgical errors (although the rapid increase in outpatient surgery makes these a growing problem) and healthcare-associated infections, pressure ulcers, and blood clots are lesser concerns. Moreover, the research focus on hospital safety also reflects the disproportionate emphasis by academic health centers on hospital care.
But interest in ambulatory safety is growing rapidly, accompanied by a number of new research and practice initiatives. Recent studies have shown that nearly 10% of adverse events occur in physician offices;2 adverse drug events and diagnostic errors are particularly common.3,4 Growing experience from outpatient-based patient safety networks indicates that ambulatory practices should focus on two main risky areas: prescription medications and the processing of lab, x-ray, and diagnostic tests.5,6 Both areas will likely be transformed by the implementation of ambulatory electronic health records and computerized prescribing, presently being driven in the United States by incentive payments to office practitioners who implement information technology (IT) systems that meet certain standards of functionality and interoperability.7,8
Sarkar et al. have proposed a model for ambulatory safety9 modified from the Chronic Care Model described by Wagner et al.10 It encompasses the three interrelated roles and relationships that influence outpatient safety:
- The role of the community and health system
- The relationship between patients and providers
- The role of patient and caregiver behaviors
The model emphasizes that ambulatory safety involves more than simply improving the flow of laboratory tests and consultations (as important as it is to fix the many problems in these systems). Errors and adverse events may relate to problems in each of these areas, and the patient's role is particularly important. Far more than in the hospital, in the ambulatory setting some patients may become unwitting participants in the genesis of errors, while others may assume some degree of responsibility for catching mistakes (Chapter 21).
This chapter highlights some of the emerging literature on ambulatory safety and reflects on some of the differences between the hospital and the clinic that may impact efforts to improve safety in the latter setting.11
In the ambulatory world, the pace is slower and the rhythm more predictable (generally driven ...