Remembering the outies: patient safety in ambulatory care

1. Remembering the outies:patient safety in ambulatory care Anne Matlow MD September 19, 2012

2. What is an ‘outie’? 1. out·ie   [ou-tee] noun Informal . 1. a protruding navel. 2. a person having such a navel. • 2. outie. Pronunciation: /ˈaʊti/ noun (plural outies) South Africaninformal a homeless person.

3. Most care happens as an • outpatient • Patients discharged from • hospital earlier • - We don’t know much about it

4. Population based need for healthcare Population 1000 Chronic Diseases Post-Acute Care Ambulatory care 250 In patient 1 JAMA 2006

5. Though some very high-quality work on ambulatory safety took place between 2000 and 2010, research and initiatives in ambulatory safety were remarkably limited, both in quantity and in the ability to generalize from the studies that were reported.

6. Institute of Medicine Report 44,000- 98,000 patients die yearly from adverse events Equivalent to 1 jumbo jet going down every 2 days 25-50% are preventable  The Hospital for Sick Children

7. 6 DIMENSIONS OF • QUALITY CARE • Safe • Effective • Patient centred • Timely • Efficient • Equitable  The Hospital for Sick Children

8. Improving Health Care Safety Efficiency Patient centered Timely Equitable Effective  The Hospital for Sick Children

9. Quality Improvement (raising the ceiling) High QUALITY OF CARE Patient Safety (raising the floor) Low Our Healthcare System

10. PATIENT SAFETY OUT- COMEOR ERROR AE Freedom from accidental injury Institute of Medicine, 1999 The simplest definition of patient safety is the prevention of errors and adverse effects to patients associated with health care. WHO Europe

11. How common are adverse events in hospital care?

12. How Common Are Adverse Events?Incidence Estimates from Hospital Chart Review Studies

13. Learning Objectives By the end of this talk, attendees will be able to… • Recognize the challenges involved in estimating the burden of medical error and harm in ambulatory care • Cite examples of common safety incidents in ambulatory care • Reflect on ways patient safety in the out-patient setting can be improved

14. How common are adverse events in ambulatory care? What are the most common types and causes of adverse events in ambulatory care?What kinds of errors are made in ambulatory care that lead to harm?

16. 15.6% said MD made a mistake 13.4% reported wrong diagnosis 12.5% wrong treatment 14.1% changed MDs

17. Ambulatory Care: A Working Definition Primary care clinics? Specialty care clinics? Surgical clinics? Physiotherapy clinics? Diagnostic imaging centres? EEG labs? Emergency Departments? Ambulatory care refers to surgeries, diagnostic procedures and treatments that do not require overnight hospitalization. http://www.health.alberta.ca/documents/ACRM-09-pt0-7.pdf

18. Bishop TF. Paid malpractice claims for adverse events in inpatient and outpatient settings JAMA June 15 2011

19. Medical errors in primary care: Results of an international study of family practice Rosser 2005 Can FamPhys 51:387

20. PROPOSED FRAMEWORK Jacobs S. Canadian Family Physician 2007; 53: 271

21. What are some patient safety hazards in ambulatory care?

22. Kistler Arch Intern Med 2010 Ki

23. Missed lab tests: 7% to 62% • Missed radiology tests: 1 to 11% • Missed mammograms: 11 to 36% • Impact on patient outomes • Missed cancer diagnosis • Hospital visits for missed hyperkalemia • Adverse drug events J Gen Intern Med 2011; Nov

24. Clinical Case • 52 year old man referred by a family physician to a gastroenterologist for iron deficiency anemia and positive occult blood in the stool • Colonoscopy performed • Poor visualization – only to the level of the mid-transverse colon • Early termination of C-scope due to patient discomfort Slide courtesy of B Wong

25. Clinical Case (cont’d) • Gastroenterologist verbally communicates to the patient that a barium enema is needed • Gastroenterologist dictates a letter to the referring GP stating his intent to organize a barium enema to rule out a right-sided colonic mass Slide courtesy of B Wong

26. Clinical Case (cont’d) • Patient is provided a follow up appointment with the gastroenterologist, but not a barium enema • Patient does not show-up because no appointment for barium enema was provided • Assumes that the gastroenterologist would want the results of the barium enema prior to the appointment Slide courtesy of B Wong

27. Seven Months Later… • Patient sees GP due to cramping abdominal pain – referral made to a general surgeon • Repeat colonoscopy reveals bleeding mass in the right colon • Biopsy confirms adenoCA of the colon • Patient undergoes urgent hemicolectomy for a locally invasive cancer with metastasized to the regional lymph nodes

28. IT is not necessarily the answer!

29. Patient factors: Non adherence Failure to inform re meds Failure to inform re S/S Provider factors: prescribing, transcription, dispensing, administration, monitoring System factors: discontinuity in care, lack of med rec, pharmacy services, non-punitive reporting

30. Importance of Effective Communication between Providers • Necessary for coordinated care • Valued by providers and patients • Improves provide satisfaction • Improves patient outcomes

31. Lost in Translation Referral with patient’s historyand reason for consultation 69% 35% FamilyDoctor Specialist 62% 81% Report with consultation resultsand advice given to patient Arch Intern Med 2011; 171(1)

32. What will YOU do??

33. Most care happens as an • outpatient • Patients discharged from • hospital earlier • - We don’t know much about it