Refocusing the lens: patient safety in ambulatory chronic disease care

Improving Patient Safety in Public Hospitals: Developing Standard Measures to Track Medical Errors and Process Breakdowns

OBJECTIVE

The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems.

METHODS

Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized. Surveys and transcripts from the meetings were analyzed to understand the decision-making process.

RESULTS

The Delphi process included eight panelists. Consensus was reached to adopt 9 of 13 proposed measures. All 9 measures were unanimously considered valid, but concern was expressed about the feasibility of implementing several of the measures.

CONCLUSIONS

Although safety net health systems face high barriers to standardized measurement, our study demonstrates that consensus can be reached on acceptable and feasible methods for tracking patient safety gaps in safety net health systems. If accompanied by the active participation key stakeholder groups, including patients, clinicians, staff, data system professionals, and health system leaders, the consensus measures reported here represent one step toward improving ambulatory patient safety in safety net health systems.

Petechiae, as seen on TV

This narrative describes how a patient facilitated a diagnosis of acute myeloid leukemia in a primary care visit because she recognized petechiae she had seen on television on her own skin.

What Safety Events Are Reported For Ambulatory Care? Analysis of Incident Reports from a Patient Safety Organization

INTRODUCTION

Health care staff document patient safety events using incident reporting systems, which are compiled within Patient Safety Organization databases. Researchers sought to describe the patterns and characteristics of incident reporting behaviors for ambulatory care from in-situ reporting systems from the United States.

METHODS

The team analyzed safety reports in ambulatory settings collected from a Patient Safety Organization comprising 400 hospital members in 10 states, from May 2012 to October 2018. All events involving moderate harm, severe harm, and death were included, as well as subsamples of events with missing harm, no harm, and mild harm. The team deductively coded incident types and if patient or caregiver challenges were involved. A multivariate logistic regression was conducted to identify predictors of higher harm (severe harm and death) among safety events reported.

RESULTS

Of 2,701 events, there were 51 deaths, 159 severe harm events, 1,180 moderate harm, 926 mild harm, 384 no harm, and 1 unknown. Most were from outpatient subspecialty care, while 5.2% were from home/community, and 2.1% were from primary care. Medication-related events were most common (45.3%). In multivariate analysis, diagnostic errors (adjusted odds ratio [aOR] 11.5), patient/caregiver challenges (aOR 2.2), and events in the home/community (aOR 2.0) and in psychiatric settings (aOR 5.0) were associated with higher harm.

CONCLUSION

Outpatient reporting systems are limited for primary care and home/community settings, but ambulatory care systems report more harmful events related to diagnosis and patient and caregiver challenges. Improved standardization of reporting, focus on diagnosis, and novel approaches of safety reporting that engage patients will be necessary to improve capture of preventable events affecting patients and to develop system-level solutions.

Patient safety in primary and outpatient health care

Primary care services provide an entry point into the health system which directly impact's people well-being and their use of other health care resources. Patient safety has been recognised as an issue of global importance for the past 10 years. Unsafe primary and ambulatory care results in greater morbidity, higher healthcare usage and economic costs. According to data from World Health Organization (WHO), the risk of a patient dying from preventable medical accident while receiving health care is 1 in 300, which is much higher than risk of dying while travelling in an airplane. Unsafe medication practices and inaccurate and delayed diagnosis are the most common causes of patient harm which affects millions of patients globally. However, majority of the work has been focussed on hospital care and there is very less understanding of what can be done to improve patient safety in primary care. Provision of safe primary care is priority as every day millions of people use primary care services across the world. The present paper focuses on various aspects of patient safety, especially in the primary care settings and also provides some potential solutions in order to reduce patient harm as much as possible. Some important challenges regarding patient safety in India are also highlighted.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

BACKGROUND

An ambulatory safety net (ASN) is an innovative organizational intervention for addressing patient safety related to missed and delayed diagnoses of abnormal test results. ASNs consist of a set of tools, reports and registries, and associated work flows to create a high-reliability system for abnormal test result management.

METHODS

Two ASNs implemented at an academic medical center are described, one focusing on colon cancer and the other on lung cancer. Data from electronic registries and chart reviews were used to evaluate the effectiveness of the ASNs, which were defined as follows: colon cancer-the proportion of patients who were scheduled for or completed a colonoscopy following safety net team outreach to the patient; lung cancer-the proportion of patients for whom the safety net was able to identify and implement appropriate follow-up, as defined by scheduled or completed chest CT.

RESULTS

The effectiveness of the colon cancer ASN was 44.0%, and the effectiveness of the lung cancer ASN was 56.9%. The ASNs led to the development of registries to address patient safety, fostered collaboration among interdisciplinary teams of clinicians and administrative staff, and created new work flows for patient outreach and tracking.

CONCLUSION

Two ASNs were successfully implemented at an academic medical center to address missed and delayed recognition of abnormal test results related to colon cancer and lung cancer. The ASNs are providing a framework for development of additional safety nets in the organization.

Defining and Measuring Adherence in Observational Studies Assessing Outcomes of Real-world Active Surveillance for Prostate Cancer: A Systematic Review

CONTEXT

Evidence-based guidelines for active surveillance (AS), a treatment option for men with low-risk prostate cancer, recommend regular follow-up at periodic intervals to monitor disease progression. However, gaps in monitoring can lead to delayed detection of cancer progression, leading to a missed window of curability.

OBJECTIVE

We aimed to identify the extent to which real-world observational studies reported adherence to monitoring protocols among prostate cancer patients on AS. When reported, we sought to characterize definitions of adherence.

EVIDENCE ACQUISITION

We systematically reviewed observational studies assessing outcomes of prostate cancer patients on AS, published before March 22, 2019 in PubMed, Embase, and CENTRAL. Adherence definitions were considered time bound if they included prespecified time and binary if adherence was assessed but did not specify a time interval. We assessed study quality using the Strengthening the Reporting of Observational Studies in Epidemiology checklist.

EVIDENCE SYNTHESIS

Forty-five studies met our inclusion criteria. Eleven studies did not report any data on adherence to AS protocols. Twenty-five studies did not explicitly measure adherence, but provided relevant data (eg, number of patients who received a repeat biopsy). Six studies reported adherence using a time-bound definition, while three studies used a binary definition. Twenty-three studies provided information on patients lost to follow-up.

CONCLUSIONS

Most studies reporting outcomes of patients on AS did not measure or report adherence. When reported, adherence was often not time specific. As some AS patients will benefit from maintaining a window of curability, clinical practices and future studies should track and report adherence and associated factors.

PATIENT SUMMARY

We reviewed real-world observational studies examining outcomes of prostate cancer patients on active surveillance. Most studies did not clearly define or report adherence to monitoring protocols, which is important to consider for appropriate disease management.

Patient Engagement In Health Care Safety: An Overview Of Mixed-Quality Evidence

Patients and caregivers play a central role in health care safety in the hospital, ambulatory care setting, and community. Despite this, interventions to promote patient engagement in safety are still underexplored. We conducted an overview of review articles on patient engagement interventions in safety to examine the current state of the evidence. Of the 2,795 references we evaluated, 52 articles met our full-text inclusion criteria for synthesis in 2018. We identified robust evidence supporting patients' self-management of anticoagulation medications and mixed-quality evidence supporting patient engagement in medication and chronic disease self-management, adverse event reporting, and medical record accuracy. Promising modes of patient engagement in safety, such as anticoagulation management and patient portal access, are not widely implemented. We discuss major implementation priorities and propose directions for future research and policy to enhance patient partnership within safety efforts.

Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers

Patient safety in ambulatory care has not been routinely measured. California implemented a pay-for-performance program in safety-net hospitals that incentivized measurement and improvement in key areas of ambulatory safety: referral completion, medication safety, and test follow-up. We present two years of program data (collected during July 2015-June 2017) and show both suboptimal performance in aspects of ambulatory safety and questionable reliability in data reporting. Performance was better in areas that required limited coordination or patient engagement-for example, annual medication monitoring versus follow-up after high-risk mammograms. Health care systems that lack seamlessly integrated electronic health records and patient registries encountered barriers to reporting reliable ambulatory safety data, particularly for measures that integrated multiple data elements. These data challenges precluded accurate performance measurement in many areas. Policy makers and safety advocates need to support the development of information systems and measures that facilitate the accurate ascertainment of the health systems, patients, and clinical tasks at greatest risk for ambulatory safety failures.

Understanding Test Results Follow-Up in the Ambulatory Setting: Analysis of Multiple Perspectives

BACKGROUND

Delayed or incomplete test result follow-up, which can lead to missed and/or delayed diagnosis, is an important issue in the ambulatory setting. Delayed test result follow-up has been linked to poorer patient outcomes and increased risk of mortality and accounts for a large portion of medical malpractice claims. Yet improvements are difficult, reflecting the complexity of the test result follow-up process. Test result follow-up safety culture was investigated using qualitative and quantitative patient safety and quality of care data at an academic medical center.

METHODS

After an environmental scan, five sources of data were used to compass multiple perspectives on safety culture-two national surveys (AHRQ MO SOPS for safety culture and CG-CAHPS for patient satisfaction); patient and family complaints; safety reports; and provider response times to test message results in the electronic health record.

RESULTS

The following metrics were inspected: how patients and providers estimated the frequency for providing timely test results; how patients' satisfaction with their provider correlated with their provider's response time to test result messages; and qualitative themes in patient complaints and safety reports filed by clinic. The institution was compared to national benchmarks using surveys. As test result response time decreased, patient satisfaction increased (p = 0.0073).

CONCLUSION

Test result follow-up culture was investigated using tools typically used to examine patient satisfaction and experience and staff culture. Use of these five sources of data led to an examination of multiple perspectives in follow-up culture and identification of possible explanations for inappropriate follow-up. These data sources can be further explored to identify possible solutions.

A survey of primary care resident attitudes toward continuity clinic patient handover

Background

Transfer of clinic patients from graduating residents to interns or junior residents occurs every year, affecting large numbers of patients. Breaches in care continuity may occur, with potential for risk to patient safety. Several guidelines have been developed for implementing standardized inpatient sign-outs, but no specific guidelines exist for outpatient handover.

Methods

Residents in primary care programs – internal medicine, family medicine, and pediatrics – at a US academic medical center were invited to participate in an online survey. The invitation was extended approximately 2 years after electronic medical record (EMR) rollout began at the institution.

Results

Of 71 eligible residents, 22 (31%) responded to the survey. Of these, 18 felt that handover of ambulatory patients was at least moderately important – but only one affirmed the existence of a system for handover. IM residents perceived that they had the highest proportion of high-risk patients (p=0.042); transition-of-care letters were more important to IM residents than other respondents (p=0.041).

Conclusion

There is room for improvement in resident acknowledgement of handover processes in continuity clinics. In this study, IM residents attached greater importance to a specific handover tool than other primary care residents. Thus, the different primary care specialties may need to have different handover tools available to them within a shared EMR system.

A Qualitative Analysis of Physician Perspectives on Missed and Delayed Outpatient Diagnosis: The Focus on System-Related Factors

BACKGROUND

Delayed and missed diagnoses lead to significant patient harm. Because physician actions are fundamental to the outpatient diagnostic process, a study was conducted to explore physician perspectives on diagnosis.

METHODS

As part of a quality improvement initiative, an integrated health system conducted six physician focus groups in 2004 and 2005. The focus groups included questions about the process of diagnosis, specific factors contributing to missed diagnosis, use of guidelines, atypical vs. typical presentations of disease, diagnostic tools, and follow-up, all with regard to delays in the diagnostic process. The interviews were analyzed (1) deductively, with application of the Systems Engineering Initiative for Patient Safety (SEIPS) model, which addresses systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes, and (2) inductively, with identification of novel themes using content analysis.

RESULTS

A total of 25 physicians participated in the six focus groups, which yielded 12 hours of discussion. Providers identified multiple barriers to timely and accurate diagnosis, including organizational culture, information availability, and communication factors.

CONCLUSIONS

Multiple themes relating to each of the participants in the diagnostic process-health system, provider, and patient-emerged. Concerns about health system structure and providers' interactions with one another and with patients far exceeded discussion of the cognitive factors that might affect the diagnostic process. The results suggest that, at least in physicians' views, improving the diagnostic process requires attention to the organization of the health system in addition to the cognitive aspects of diagnosis.

Electronic Clinical Surveillance to Improve Outpatient Care: Diverse Applications within an Integrated Delivery System

Efforts to improve patient safety have largely focused on inpatient or emergency settings, but the importance of patient safety in ambulatory care is increasingly being recognized as a key component of overall health care quality. Care gaps in outpatient settings may include missed diagnoses, medication errors, or insufficient monitoring of patients with chronic conditions or on certain medications. Further, care gaps may occur across a wide range of clinical conditions. We report here an innovative approach to improve patient safety in ambulatory settings – the Kaiser Permanente Southern California (KPSC) Outpatient Safety Net Program – which leverages electronic health information to efficiently identify and address a variety of potential care gaps across different clinical conditions.

Between 2006 and 2012, the KPSC Outpatient Safety Net Program implemented 24 distinct electronic clinical surveillance programs, which routinely scan the electronic health record to identify patients with a particular condition or event. For example, electronic clinical surveillance may be used to scan for harmful medication interactions or potentially missed diagnoses (e.g., abnormal test results without evidence of subsequent care). Keys to the success of the program include strong leadership support, a proactive clinical culture, the blame-free nature of the program, and the availability of electronic health information. The Outpatient Safety Net Program framework may be adopted by other organizations, including those who have electronic health information but not an electronic health record. In the future, the creation of a forum to share electronic clinical surveillance programs across organizations may facilitate more rapid improvements in outpatient safety.

Safety risks in the ambulatory setting

Over the past decade, the focus of safety implementation has been on hospital settings, and most research on patient safety has examined hospital care. Yet, each year, 300 Americans are seen in ambulatory settings for every 1 person admitted to a hospital, and research shows that errors in ambulatory settings can be just as devastating as those in hospitals, and, as in the hospital setting, ambulatory errors or events often trigger legal action. The American Medical Association's report summarizing and compiling the past decade's research identifies 3 general gaps in the current research that impede safety analysis and 6 errors that are most common in ambulatory care that warrant attention. As new models of care emerge with an increased focus on continuity across care settings, there are also nascent opportunities for risk managers to analyze and evaluate ambulatory safety, implement strategies, and develop and test tools that could result in safer patient outcomes.

Personal health records: a randomized trial of effects on elder medication safety

PURPOSE

To examine the impact of a personal health record (PHR) on medication-use safety among older adults.

BACKGROUND

Online PHRs have potential as tools to manage health information. We know little about how to make PHRs accessible for older adults and what effects this will have.

METHODS

A PHR was designed and pretested with older adults and tested in a 6-month randomized controlled trial. After completing mailed baseline questionnaires, eligible computer users aged 65 and over were randomized 3:1 to be given access to a PHR (n=802) or serve as a standard care control group (n=273). Follow-up questionnaires measured change from baseline medication use, medication reconciliation behaviors, and medication management problems.

RESULTS

Older adults were interested in keeping track of their health and medication information. A majority (55.2%) logged into the PHR and used it, but only 16.1% used it frequently. At follow-up, those randomized to the PHR group were significantly less likely to use multiple non-steroidal anti-inflammatory drugs-the most common warning generated by the system (viewed by 23% of participants). Compared with low/non-users, high users reported significantly more changes in medication use and improved medication reconciliation behaviors, and recognized significantly more side effects, but there was no difference in use of inappropriate medications or adherence measures.

CONCLUSIONS

PHRs can engage older adults for better medication self-management; however, features that motivate continued use will be needed. Longer-term studies of continued users will be required to evaluate the impact of these changes in behavior on patient health outcomes.

Adverse drug events in U.S. adult ambulatory medical care

OBJECTIVE

To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings.

DATA SOURCE

We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys.

STUDY DESIGN

Secondary data analysis.

PRINCIPAL FINDINGS

An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]).

CONCLUSIONS

Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.