Patient Safety In Ambulatory Care System

While most prior research in patient safety has focused on preventing medical errors during hospital stays, the UCSF team emphasizes that more attention should be paid to chronic disease patients who receive care on an outpatient basis.

The team’s analysis appears in the July 2009 edition of the Joint Commission Journal on Quality and Patient Safety in an article titled “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care.”  The article describes how gaps in the current health care system undermine safety in the outpatient setting, leading to preventable death and disability as well as unnecessary costs.

Unlike acute care settings, where patients receive care from trained teams of clinicians guided by protocols, the outpatient setting involves patients performing the day-to-day self-management of their chronic conditions, often in the absence of clear protocols, said lead author Urmimala Sarkar, MD, MPH, assistant professor of medicine in the UCSF Division of General Internal Medicine and the Center for Vulnerable Populations at San Francisco General Hospital Medical Center.

The authors assert that ambulatory settings present unique challenges, such as lack of communication between health systems, communities with inadequate resources, and patients struggling to manage multiple medications and complicated treatment regimens. They aim to refocus attention on the issue of ambulatory patient safety, because they have seen the adverse effects of medical errors in their own outpatient practices.

“As a resident, I saw one of my patients who had just been discharged from the hospital,” said Sarkar, “and I found that she was taking literally four times the maximum dose of her blood pressure medication. The medication overdose gave her kidney failure, and I had to send her right back to the hospital.”

The article, which appears in the journal’s “Forum” section, is the first to present a conceptual framework for advancing the field of ambulatory patient safety in chronic disease management.  It uses actual clinical cases to illustrate the interrelated ways that communities and health systems, patient-provider interactions, and health behaviors all impact patient safety.

To improve safety for chronic disease populations, the authors advocate first to improve patients’ and caregivers’ capacity for self-management.  This includes targeting safety promotion efforts to those most at risk, including individuals with limited English proficiency, limited health literacy, and those with other social vulnerabilities, such as poverty and food insecurity.  The team notes that patients with limited health literacy and language barriers report greater problems across a range of communications issues, including informed consent, shared decision making, and addressing health concerns with their providers.

The authors also recommend that clinicians in ambulatory health systems develop more robust health information technology systems, especially for safety surveillance; improve communication among providers and patients, especially for transitions in care; and develop and implement interventions to better prepare and support patients to safely manage their chronic disease at home. Moreover, clinicians should weigh the risk of intensifying treatment regimens with potential risks and adverse events that could arise in the ambulatory setting, according to the authors.

Co-authors of the article are Robert M. Wachter, MD, Lynne and Marc Benioff endowed chair in hospital medicine, chief of the Division of Hospital Medicine, and chief of the Medical Service, UCSF Medical Center; Steven A. Schroeder, MD, distinguished professor of health and health care, UCSF Department of Medicine; and Dean Schillinger, MD, professor of medicine at UCSF, director of the Center for Vulnerable Populations at SFGH, and program chief of the California Diabetes Program.

Sarkar’s work is supported by a grant from the Agency for Healthcare Research and Quality. Schillinger’s work is supported by a grant from the Agency for Healthcare Research and Quality and a National Institutes of Health Clinical and Translational Science Award.