AMA urges greater focus on ambulatory care safety

By Bernie Monegain
10:31 AM

Outpatient visits can put some patients at risk, according to a new report from the American Medical Association. The report concludes that research is lacking in this area, and calls for greater and more focused attention, intervention and resources on ambulatory care safety.

While the report acknowleges that electronic medical records could boost safety, the authors take a wait-and-see approach.

“The use of electronic health records has the potential to improve patient safety and early research shows some promise,” the report notes, “but these systems have also been linked to errors and harm. It is not yet clear how many providers will adopt these systems, nor the extent to which health IT will improve patient safety in ambulatory care versus generating new types of errors.”

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"Research in Ambulatory Patient Safety 2000–2010: A Ten-Year Review" assesses existing research on the topic, which the AMA notes was limited to a few sites.

For example, two sites (Brigham and Women’s Hospital in Boston and the Michael E. DeBakey VA Medical Center in Houston) contributed six of 10 original studies related to ambulatory communication errors.

“With some notable exceptions, much of the work on patient safety in ambulatory care since 2000 has focused on identifying errors, whether or not they resulted in harm, rather than on actual harm to patients,” the report notes. “This focus has not been wholly consistent with the IOM definition of patient safety as 'freedom from accidental injury.'"

The authors have arrived at various conclusions regarding the nature and causes of errors and harm occurring in ambulatory care settings. However, certain themes are discernable. In particular, research over the last decade has shown that some of the most widely documented ambulatory errors include:

  1. Medication errors such as prescriptions for incorrect drugs or incorrect dosages
  2. Diagnostic errors such as missed, delayed and wrong diagnoses
  3. Laboratory errors such as missed and delayed tests as well as errors in patient follow-up on test results
  4. Clinical knowledge errors such as knowledge, skill and general performance errors on the part of
  5. Communication errors such as doctor-patient communication errors, doctor-doctor communication errors or other miscommunications between parties
  6. Administrative errors such as errors in scheduling appointments and managing patient records

Research on broad-based interventions to improve patient safety has been much less frequent than research on the most common causes of errors.

The report cites the Patient Safety and Quality Improvement Act of 2005 and the work of the Agency for Healthcare Research and Quality (AHRQ) as working to improve safety. The AHRQ has called for further research in the  role of information technology to improve ambulatory patient safety, including computerized physician order entry and electronic medical records.

The AMA report highlights the provisions for meaningful use that may boost safety. Some of the requirements for office-based practices to qualify for financial incentives are to use an EHR for:

  • Maintaining active problem, medication and medication allergy lists on an EHR system
  • Using computerized physician order entry with drug-drug and drug-allergy checks
  • e-prescribing (including electronic submission of the prescription to the pharmacy)
  • Providing the patient an encounter summary after each visit
  • Testing the capability to exchange electronically clinical information among providers
  • Some optional activities include:
  • Reconciling medications at transitions in care
  • Providing a summary record for transitions in care
  • Providing patients with electronic access to their information stored in the HER
  • Sending reminders for follow-up care for patients over 65 or under 5


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