Top 5 Patient Safety Risks in Ambulatory Care

Megan Brooks

October 25, 2019

Diagnostic testing errors and medication events are the most common safety risks patients face in ambulatory care, followed by falls and problems involving privacy and personal security, according to a new report from the ECRI Institute's Patient Safety Organization.

The report, Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety and Risk Reduction, provides a snapshot of these top safety challenges in the outpatient setting and offers potential solutions.

"As healthcare delivery shifts from hospitals to ambulatory care settings, it can be challenging to coordinate care among various clinicians, systems, and facilities, raising the potential for errors that put patients at risk," Marcus Schabacker, MD, PhD, president and CEO of the ECRI Institute, said in a news release.

"Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination," he said.

Errors in Lab and Imaging Tests, Medications

The ECRI Institute analyzed 4355 adverse events reported by physician practices (56%), ambulatory care centers (30%), and community health centers (14%) over a 12-month period from December 2017 to November 2018.

Nearly half (47%) of the events involved diagnostic testing errors, which could result in missed or delayed interventions leading to adverse or fatal outcomes. Diagnostic testing errors may also lead to duplication of services, performance of unnecessary tests, patient and family dissatisfaction, and litigation.

More than two thirds (69%) of diagnostic testing events reported to the ECRI Institute involved laboratory tests, and more than one fifth (21%) involved imaging tests. Solutions to these problems include providing decision support tools to providers and monitoring processes for test tracking and follow-up.

Next on the list are medication safety events (27%), which usually resulted from a series of failures within a system and involved many people, processes, and systems, the report notes.

Two thirds (67%) of medication safety–related events fell into the category of "wrong" errors; 34% were wrong-drug errors, 17% were drug overdose errors, and 16% were wrong-patient errors. Other errors included giving the drug at the wrong time, at the wrong rate, or at the wrong strength.

Medication errors are a leading cause of malpractice claims in ambulatory care, the report notes. Solutions include implementing standardized medication management procedures and creating a policy that directs how to report and manage safety events.

Falls, Privacy, and Security Risks

The report also highlights the problem of patient falls in ambulatory care. Falls accounted for 14% of the events. One third (33%) of the falls analyzed by ECRI occurred in the exam room, and a quarter (25%) occurred in the waiting room/office. An additional quarter (24%) occurred outside, on the facility grounds.

Solutions include screening for falls and proactively identifying patients at high risk. The report also recommends that a "flag" appear in the electronic health record to alert the ordering clinician that the medication carries a fall risk.

Next on the list of patient safety risks in outpatient settings is misunderstanding regarding Health Insurance Portability and Accountability Act (HIPAA) privacy and security rules; more than 350 HIPAA-related events (8%) were reported to the ECRI Institute.

Most of these involved the inadvertent disclosure of patients' protected health information. These HIPAA-related events often go underreported, either because staff do not recognize them as violations or because the incidents are considered too insignificant to report.

Security and safety incidents in ambulatory care also made the list, at 5% of the overall events. The vast majority of these problems involved verbal threats or disruptive behavior by patients or visitors. Solutions include educating staff on what to do during a violent incident and conducting monthly security and safety surveillance rounds.

The data reported to the ECRI Institute's patient safety database are provided voluntarily and are based on spontaneous reports from staff, the organization notes. It is likely that many other events involving problems in ambulatory care occurred during the period of the analysis but were not recognized or reported.

"The data in this report," they add, "provide important insights but do not represent the incidence or prevalence of events involving ambulatory care settings."

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