Executive Summary
Recent research suggests outpatient safety does not get as much attention as inpatient safety. Risk managers should direct more attention to this area.
- Outpatient safety often is not adequately included in safety efforts.
- Metrics to measure outpatient safety are different from those used for inpatients.
- Adverse drug events with the most common error in outpatient settings.
Despite years of efforts to improve patient safety, recent research indicates that nearly all the attention has been on inpatient care. Outpatient safety is being neglected and needs far more attention, researchers say.
The number of adverse events in the outpatient setting may surprise some healthcare professionals, says David M. Levine, MD, MPH, MA, with the Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School in Boston.
In a recent study led by Levine, nurse reviewers identified possible adverse events and physicians assessed them for severity and preventability. They used generalized estimating equations to assess the association of having at least one adverse event with age, sex, race, and primary insurance.
The 3,103 patients were more often female (59.8%), white (75.1%), English speakers (90.8%), and privately insured (70.4%), the study report says. They had a mean of four outpatient encounters in 2018. Seven percent of patients had at least one adverse event, with adverse drug events being the most common, accounting for 63.8%.
Healthcare-associated infections were second at 14.8% and surgical or procedural events accounted for 14.2%. Severity was assessed as serious in 17.4% of the adverse events and life-threatening in 2.1%. None were fatal. The researchers determined that 23.2% of the outpatient adverse events were preventable. Having at least one adverse event was less often associated with ages 18 to 44 years than with ages 65 to 84 years and more often associated with Black patients than with Asian ones. (The study is available online at https://bit.ly/3L2Mt7P.)
The study is one of the largest looks at adverse events in the outpatient setting, Levine says. The first important takeaway from the research is that there are a lot of adverse events in the outpatient setting, he says.
“Unfortunately, we don’t really measure them right now in a very structured way, and this is one of the first looks at seeing how, unfortunately, outpatient harm is relatively common, and it’s often serious,” Levine says. “One of the bigger things that we saw is that adverse drug events were very frequent in the outpatient setting, and adverse events are happening more among older adults. So, we need to be more conscientious among our older adult patients, for sure.”
Unfortunately, there are not a lot of evidence-based interventions in the outpatient setting to improve patient safety, Levine says. That means there must be an urgent call for interventions in the healthcare industry, he says.
“Health systems, researchers, directors, and administrators need to really push their teams to start to innovate, to create the interventions and the improvements that we need in the outpatient setting in order to improve safety for our patients,” Levine says, adding that the first step is to start measuring outpatient harm.
“This study really is a call to action. Before this, nobody really knew how much harm was even happening. Nobody’s measuring this right now. And many, many people much smarter than myself have said, ‘If you don’t measure it, you don’t know what’s even happening,’” Levine says. “They can take the exact same measurements that we did in this paper and apply them to their patients and their clinics and their providers and their groups in order to see how well they are doing. If they’re not doing all that, well, maybe then that’s where they need to start innovating into new ways of protecting patients.”
However, Levine cautions that it will not be as easy as just applying the same patient safety metrics used in inpatient care. Outpatient metrics are different, although there is some overlap, he says. It also is easy to assume that if you are doing a good job with inpatient safety, outpatient safety is doing just as well. But Levine says that is not likely true, even if the inpatient metrics could be trusted. “I’m not even sure people are measuring inpatient safety all that well, either. Research has documented very high levels of harm in the inpatient setting, and again, people are not measuring it,” Levine says. “They all think they’re doing a great job and everything’s hunky dory, things are fine. And they’re not. We’re causing a lot of healthcare-related harm, unfortunately.”
More research and transparency on outpatient safety is needed to make any significant improvements, he says.
“One of the big calls to action here is not only let’s measure it, please, but also let’s figure out how to fix it. Inpatient medicine has tried to do some of that, but we don’t have those kinds of interventions in the outpatient setting,” Levine says. “Nobody is studying those in the same way and trying to improve care in the same way as much. That’s where we’ll really be looking to help improve care.”
Source
- David M. Levine, MD, MPH, MA, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, and Harvard Medical School in Boston. Email: [email protected].
Despite years of efforts to improve patient safety, recent research indicates that nearly all the attention has been on inpatient care. Outpatient safety is being neglected and needs far more attention, researchers say.
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