The Exchange

Commentary and Observations from
the Medical Front Lines

Mistakes in the Ambulatory Care Setting

Mistakes in the Ambulatory Care Setting

A report published in late October entitled "Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety and Risk Reduction" gives a clear view into the kinds of errors that are occurring in the ambulatory care setting. The Agency for Healthcare Research and Quality used the 2018 User Database Report on its Medical Office Survey on Patient Safety Culture encompassing 35,523 staff respondents from 2437 medical offices including physician practices (56%), ambulatory care centers (30%), and community health centers (14%). A total of 4355 events were analyzed over the year.

This is a small fraction of the ambulatory care facilities, and these data are self-reported, so it is felt that the vast majority of errors go unreported. The report is very clear in stating: "The data in this report provide important insights but do not represent the incidence or prevalence of events involving ambulatory care settings."

The actual number of ambulatory care events is impossible to estimate, but is likely thousands of times larger than the number examined in the report. While we get a good sense as to how the errors are distributed, that errors of these types continue to occur with such high frequency is truly frightening.

Nearly half (47%) of the events involved diagnostic testing errors which resulted in erroneous or delayed treatments and led to adverse or fatal outcomes. Diagnostic testing errors also have other significant downstream implications: performance of additional and unnecessary tests, patient and family dissatisfaction, and, of course, malpractice litigation. More than two thirds (69%) of the diagnostic testing errors reported involved laboratory tests, and more than one fifth (21%) involved imaging tests.

It is incredible to me that medication safety events accounted for the next largest group of error, and even more so that they continue unabatedaccounting for 27% of reported medical errors. Sixty-seven percent of medication safety-related events fell into a broad category labeled as "wrong" errors: 34% were wrong-drug errors, 17% were drug overdose errors, and 16% were wrong-patient errors. Other errors included giving the drug at the wrong time, at the wrong rate, or at the wrong strength.

We simply have to do better.


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Filed under: Health Policy and Trends, Practice Management/Career, Public Health

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