Outpatient settings need to be safer, study finds

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Patient safety events, which are adverse events that could have been prevented, are altogether common in outpatient settings and speak to the need for improving safety in these settings, according to a new study in the Annals of Internal Medicine.

Outpatient settings include primary care visits, specialty care appointments, day surgeries, visits to the emergency room and other settings where patients receive most of their care.

To better understand patient safety in the outpatient setting, a team from Boston area hospitals used data from a SafeCare Study to analyze the care of patients seen in outpatient practices from four healthcare systems in Massachusetts in 2018.

Led by investigators from Mass General Brigham, and sponsored by CRICO, the medical professional liability insurer for the Harvard medical community and its affiliated organizations, authors called the study an "alarm bell."

"If we do not measure outpatient safety, we cannot start to improve care for all patients," said corresponding author Dr. David Levine, of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital, a founding member of Mass General Brigham. "Our study focuses on data that highlights what is a national and international issue for patients."

WHAT'S THE IMPACT?

Despite how frequently patients receive outpatient care, few studies have focused on this setting, and most of the studies that have done so to date have been limited and their findings have been imprecise, authors said.

For the current study, researchers conducted a retrospective review of adverse events that occurred in the outpatient setting in 2018. They used all available data found in 3,103 electronic health records for a random sample of patients aged 18 and over from 11 outpatient care facilities.

Seven nurse reviewers identified possible adverse events by identifying relevant triggers noted in the EHRs. If a nurse found an adverse event in the EHR, they would hand the information to a physician adjudicator who determined whether it was indeed an adverse event. They then ranked the severity of the adverse event, assessed whether it was preventable and rated their confidence using a six-point scale.

They found 7% of patients experienced at least one adverse event in the outpatient setting and 1.9% of patients experienced at least one preventable adverse event. The most common adverse events were adverse drug events (63.8%), healthcare-associated infections (14.8%), surgical/procedural adverse events (14.2%), patient care adverse events (8.3%) and perinatal/maternal adverse events (0.7%).

The team also found almost half of the adverse events occurred in the physician's office, where patients more frequently receive care. For every 100 ED visits, about two adverse events occurred, while adverse events occurred in the physician's office for about one out of every 100 ambulatory encounters.

The researchers also found that adverse events disproportionately affected older adults. Among patients over 85 years old, many had preventable (8.7%) and serious (4.4%) adverse events.

Investigators noted several limitations in the study. Since they analyzed and collected data retrospectively, some patient information may not have been captured in the EHRs. In addition, the team couldn't access relevant data from patients who left the institutions from which the study data was collected.

The investigators did not include the safety implications for telehealth, which was practiced infrequently in 2018.

THE LARGER TREND

Prior research has shown that adverse events can also be prevalent in inpatient settings. Almost 25% of inpatient admissions in 2018 experienced at least one adverse event while 7% experienced a preventable adverse event, according to data published in 2023 in The New England Journal of Medicine.

The analysis, which looked at about 2,800 admissions across 11 hospitals, found 978 adverse events, many of them serious, and a small percentage – 1% – that were both serious and preventable.

Such events have been a consistent problem for decades. Researchers pointed to the 1991 Harvard Medical Practice Study, which uncovered similar findings from more than 30 years ago. The HMPS attributed almost 30% of adverse events to provider negligence, though narrower criteria at the time meant pulling from a smaller sample size.

The Leapfrog Group regularly reports patient safety in the hospital setting. Its latest 2024 Hospital Safety Grades indicates improvement since the fall of 2023. Preventable healthcare-associated infections have decreased after unprecedented rates during the height of the pandemic, said the independent nonprofit patient safety organization.

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.