Remembering the outies:patient safety in ambulatory care

Anne Matlow MDSeptember 19, 2012

What is an ‘outie’?

1. out·ie   [ou-tee] noun Informal .1. a protruding navel.2. a person having such a navel.

• 2. outie. Pronunciation: /ˈaʊti/noun (plural outies)South African informala homeless person.

- Most care happens as an outpatient

- Patients discharged from hospital earlier

- We don’t know much about it

Population based need for healthcare

Population 1000

Ambulatory care 250

1In patient

JAMA 2006

Chronic DiseasesPost-Acute Care

Though some very high-quality work on ambulatory safety took place between 2000 and

2010, research and initiatives in ambulatory safety were remarkably limited, both in quantity and in

the ability to generalize from the studies that were reported.

The Hospital for Sick Children6

Institute of Medicine Report

44,000- 98,000 patients die yearly from adverse eventsEquivalent to 1 jumbo jet going down every 2 days

25-50% are preventable

The Hospital for Sick Children 7

6 DIMENSIONS OFQUALITY CARE•Safe•Effective•Patient centred•Timely•Efficient•Equitable

The Hospital for Sick Children 8

Improving Health Care

SafetyEfficiencyPatient centeredTimelyEquitableEffective

Our Healthcare System

High

QU

ALIT

Y O

F C A

R E

Low

Quality Improvement (raising the ceiling)

Patient Safety(raising the floor)

PATIENT SAFETYFreedom from accidental injury Institute of Medicine, 1999

The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated

with health care. WHO Europe

ERROROUT-

COMEOR

AE

How common are adverse events in hospital care?

How Common Are Adverse Events? Incidence Estimates from Hospital Chart Review Studies

Country N Year Incidence of AE

Preventable?

Canada 3,745 2000 7.5% 37%

USA (U&C)

14,700 1992 2.9% Not reported

Australia 14,179 1992 16.6% 51%

UK 1,014 1999 10.8% 48%

New Zealand

1,326 1998 12.9% 37%

USA (NY) 30,195 1984 3.7 % Not reported

Learning Objectives

By the end of this talk, attendees will be able to…• Recognize the challenges involved in estimating

the burden of medical error and harm in ambulatory care

• Cite examples of common safety incidents in ambulatory care

• Reflect on ways patient safety in the out-patient setting can be improved

How common are adverse events in ambulatory care?

What are the most common types and causes of adverse events in ambulatory care?

What kinds of errors are made in ambulatory care that lead to harm?

15.6% said MD made a mistake13.4% reported wrong diagnosis12.5% wrong treatment14.1% changed MDs

Ambulatory care refers to surgeries, diagnostic procedures and treatments

that do not require overnight hospitalization.

http://www.health.alberta.ca/documents/ACRM-09-pt0-7.pdf

Ambulatory Care: A Working Definition

Primary care clinics?Specialty care clinics?

Surgical clinics?Physiotherapy clinics?

Diagnostic imaging centres?EEG labs?

Emergency Departments?

Bishop TF. Paid malpractice claims for adverse events in inpatient and outpatient settings JAMA June 15 2011

Medical errors in primary care: Results of an international study of family practice

Rosser 2005 Can Fam Phys 51:387

PROPOSED FRAMEWORK

Jacobs S. Canadian Family Physician 2007; 53: 271

What are some patient safety hazards in ambulatory care?

KiKistler Arch Intern Med 2010

• Missed lab tests: 7% to 62%• Missed radiology tests: 1 to 11%• Missed mammograms: 11 to 36%

• Impact on patient outomes– Missed cancer diagnosis– Hospital visits for missed hyperkalemia– Adverse drug events

J Gen Intern Med 2011; Nov

Clinical Case

• 52 year old man referred by a family physician to a gastroenterologist for iron deficiency anemia and positive occult blood in the stool

• Colonoscopy performed– Poor visualization – only to the level of the mid-

transverse colon– Early termination of C-scope due to patient

discomfort

Slide courtesy of B Wong

Clinical Case (cont’d)

• Gastroenterologist verbally communicates to the patient that a barium enema is needed

• Gastroenterologist dictates a letter to the referring GP stating his intent to organize a barium enema to rule out a right-sided colonic mass

Slide courtesy of B Wong

Clinical Case (cont’d)

• Patient is provided a follow up appointment with the gastroenterologist, but not a barium enema

• Patient does not show-up because no appointment for barium enema was provided– Assumes that the gastroenterologist would want

the results of the barium enema prior to the appointment

Slide courtesy of B Wong

Seven Months Later…

• Patient sees GP due to cramping abdominal pain – referral made to a general surgeon

• Repeat colonoscopy reveals bleeding mass in the right colon

• Biopsy confirms adenoCA of the colon• Patient undergoes urgent hemicolectomy for a

locally invasive cancer with metastasized to the regional lymph nodes

IT is not necessarily the answer!

Provider factors: prescribing, transcription,

dispensing, administration,monitoring

Patient factors:Non adherence

Failure to inform re medsFailure to inform re S/S

System factors: discontinuity in care, lack of med rec, pharmacy services,

non-punitive reporting

Importance of Effective Communication between Providers

• Necessary for coordinated care• Valued by providers and patients• Improves provide satisfaction• Improves patient outcomes

Lost in Translation

FamilyDoctor Specialist

Referral with patient’s historyand reason for consultation

Report with consultation resultsand advice given to patient

Arch Intern Med 2011; 171(1)

69% 35%

81%62%

What will YOU do??

- Most care happens as an outpatient

- Patients discharged from hospital earlier

- We don’t know much about it