4 Top Patient Safety Risks in Ambulatory Care

A new report identifies diagnostic errors as the top patient safety risk in ambulatory care settings.

A watchdog group has identified the top four risks for patient safety at ambulatory care settings, according to a new report.

Ambulatory care facilities such as physician offices and outpatient clinics are the most widely used settings in U.S. healthcare, according to the ECRI Institute PSO report published last week. Ambulatory care settings provide a wide range of services to patients such as consultation, diagnosis, and interventions.

"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. Reducing and eliminating adverse events in an outpatient environment will require an unprecedented commitment to collaboration and coordination," Marcus Schabacker, MD, PhD, president and CEO of the ECRI Institute, said in a prepared statement.

The watchdog group is based in Plymouth Meeting, Pennsylvania.

According to the ECRI Institute PSO (patient safety organization) report, the top four risks for patient safety at ambulatory care settings are diagnostic testing errors, medication events, falls, and security incidents.

ECRI Institute PSO examined more than 4,300 ambulatory care patient safety events from December 2017 to November 2018. Diagnostic testing errors accounted for the most events (47%), followed by medication safety events (27%). Highlights of the findings and recommendations are below.

1. Diagnostic testing errors

Patients can experience several negative impacts from diagnostic testing errors such as missed or delayed diagnoses, delayed interventions, and duplication of services. According to the ECRI Institute PSO report, the most common diagnostic testing errors involved laboratory tests (69%), followed by imaging tests (21%).

The report's recommendations to curb diagnostic testing errors include the following:

• Establish decision support tools to help clinicians order appropriate tests
   
• Establish processes for communicating test results such as a chain of command that includes a reporting provision when the clinician who ordered a test is absent
   
• Establish standard operating procedures in writing for specimen, collection, preparation, and delivery

2. Medication events

Medication safety events are a leading cause of malpractice claims in ambulatory care. In a Coverys analysis of more than 10,000 closed malpractice claims, medication errors were the fourth most common cause of medical professional liability claims, and 42% of the errors occurred in an ambulatory setting.

In the ECRI Institute PSO analysis, the most common medication safety event (67%) involved "wrong" errors such as wrong patient or wrong drug, followed by monitoring errors (16%). "Such events can occur during any stage of the medication process and are rarely the fault of one person; rather, as with most adverse events, they result from a series of failures within a system," the ECRI Institute PSO report says.

The report's recommendations to reduce medication errors include the following:

• Identify priority areas for medication safety improvement such as medication-event reporting and medication safety education
   
• Establish standardized policies and procedures that feature best practices for each phase of the medication management process
   
• Establish and communicating management processes for high-alert medications such as chemotherapy drugs, including storage and administration

3. Patient falls

Patient falls accounted for 14% of the events in the ECRI Institute PSO analysis, with most falls occurring in the physician practice setting.

"Falls are often preventable occurrences that can lead to patient injury, cause hospitalizations, and significantly increase healthcare costs. Falls occurring in hospitalized patients are a major source of risk for acute and long-term care providers. In ambulatory care, screening for the risk of falls is an important component of preventing falls whether in the office setting, at home, or elsewhere," the report says.

The report's recommendations to decrease falls include the following:

• Screen patients for falls during every visit, when there is a change in medical condition, and after a fall
   
• Train staff to identify fall risks during a range of patient interactions such as welcoming and conducting medical assessments
   
• In the electronic medical record, flag prescriptions of medications that have a fall risk when the drug is ordered and during medication reconciliation

4. Security incidents

About three-quarters of U.S. workplace assaults occur in healthcare settings, according to a federal Occupational Safety and Health Administration report. Most of the security events examined in the ECRI Institute PSO analysis involved verbal threats or disruptive behavior by patients or patient visitors.

"Unfortunately, security and safety issues, such as workplace violence, are common in healthcare, including ambulatory care settings. Although most episodes of disruptive behavior or violent acts are perpetrated by patients, some are perpetrated by family members of patients, other visitors, employees, or ill-meaning trespassers," the ECRI Institute PSO report says.

The report's recommendations to address security incidents include the following:

• Establish a well-resourced workplace violence prevention program
   
• On at least an annual basis, conducting an all-hazards risk assessment that includes patient risks, environmental risks, and operational risks that gauge the potential for violence
   
• On at least a monthly basis, have security and safety surveillance rounds