remembering the outies: patient safety in ambulatory care anne matlow md september 19, 2012
TRANSCRIPT
Remembering the outies:patient safety in ambulatory care
Anne Matlow MDSeptember 19, 2012
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 African informala homeless person.
- Most care happens as an outpatient
- Patients discharged from hospital earlier
- We don’t know much about it
Population based need for healthcare
Population 1000
Ambulatory care 250
1In patient
JAMA 2006
Chronic DiseasesPost-Acute Care
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.
The Hospital for Sick Children6
Institute of Medicine Report
44,000- 98,000 patients die yearly from adverse eventsEquivalent to 1 jumbo jet going down every 2 days
25-50% are preventable
The Hospital for Sick Children 7
6 DIMENSIONS OFQUALITY CARE•Safe•Effective•Patient centred•Timely•Efficient•Equitable
The Hospital for Sick Children 8
Improving Health Care
SafetyEfficiencyPatient centeredTimelyEquitableEffective
Our Healthcare System
High
QU
ALIT
Y O
F C A
R E
Low
Quality Improvement (raising the ceiling)
Patient Safety(raising the floor)
PATIENT SAFETYFreedom 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
ERROROUT-
COMEOR
AE
How common are adverse events in hospital care?
How Common Are Adverse Events? Incidence Estimates from Hospital Chart Review Studies
Country N Year Incidence of AE
Preventable?
Canada 3,745 2000 7.5% 37%
USA (U&C)
14,700 1992 2.9% Not reported
Australia 14,179 1992 16.6% 51%
UK 1,014 1999 10.8% 48%
New Zealand
1,326 1998 12.9% 37%
USA (NY) 30,195 1984 3.7 % Not reported
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
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?
15.6% said MD made a mistake13.4% reported wrong diagnosis12.5% wrong treatment14.1% changed MDs
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
Ambulatory Care: A Working Definition
Primary care clinics?Specialty care clinics?
Surgical clinics?Physiotherapy clinics?
Diagnostic imaging centres?EEG labs?
Emergency Departments?
Bishop TF. Paid malpractice claims for adverse events in inpatient and outpatient settings JAMA June 15 2011
Medical errors in primary care: Results of an international study of family practice
Rosser 2005 Can Fam Phys 51:387
PROPOSED FRAMEWORK
Jacobs S. Canadian Family Physician 2007; 53: 271
What are some patient safety hazards in ambulatory care?
KiKistler Arch Intern Med 2010
• 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
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
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
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
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
IT is not necessarily the answer!
Provider factors: prescribing, transcription,
dispensing, administration,monitoring
Patient factors:Non adherence
Failure to inform re medsFailure to inform re S/S
System factors: discontinuity in care, lack of med rec, pharmacy services,
non-punitive reporting
Importance of Effective Communication between Providers
• Necessary for coordinated care• Valued by providers and patients• Improves provide satisfaction• Improves patient outcomes
Lost in Translation
FamilyDoctor Specialist
Referral with patient’s historyand reason for consultation
Report with consultation resultsand advice given to patient
Arch Intern Med 2011; 171(1)
69% 35%
81%62%
What will YOU do??
- Most care happens as an outpatient
- Patients discharged from hospital earlier
- We don’t know much about it