Study points to patient safety risks outside hospital walls

June 14, 2011

Ever since the Institute of Medicine issued its landmark report "To Err Is Human" in 1999, significant attention has been paid to improving patient safety in hospitals nationwide.

However, a high number of adverse events, including major injury and even death, occur in private physician offices and outpatient clinics as well. In a new study -- the first of its kind -- researchers at Weill Cornell Medical College found that the number and magnitude of events resulting from medical errors is surprisingly similar inside and outside hospital walls.

Published in today's (JAMA), the study uses data to assess the prevalence of adverse events in the outpatient setting. The researchers compared malpractice claims paid on behalf of physicians in hospitals versus doctors' offices, relying on data from the National Practitioner Data Bank from 2005 through 2009.

In 2009 alone, close to 11,000 malpractice payments were made on behalf of physicians. Analysis of the data showed that about half of these were for errors that occurred in the hospital setting and half for adverse outcomes resulting from errors at the doctor's office.

The researchers also found that adverse events in hospitals largely have to do with unsuccessful surgery, while negative outcomes in the outpatient setting are most often related to errors in diagnosis.

"Physician practices have not been the focus of research, much less of policy efforts to reduce medical error," says Dr. Tara Bishop, lead author of the new study and assistant professor of public health and medicine at Weill Cornell Medical College and a practicing physician at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

Dr. Bishop and her co-authors -- all members of the Weill Cornell Medical College faculty -- hope to stimulate interest in this neglected arena with a view toward improving the safety record of outpatient care.

In contrast to the large, centralized nature of the hospital setting, outpatient care is prone to fragmentation. "Our findings may reflect a lack of coordination within and between doctors' offices," Dr. Bishop says. "For example, a primary care physician may refer a patient to a specialist -- but the actual appointment may never happen. A cardiologist may order a scan, unaware that it was already performed during a patient's hospital stay.

"The problems associated with outpatient safety may not be easy to fix, but the adoption of electronic health records is already improving communication between doctors," says Dr. Bishop.

"Patient safety is likely to improve markedly as more and more doctors' offices change the way their records are kept, updated and accessed."

In addition to diagnostic errors and adverse drug interactions, surgical errors are occurring with greater frequency in the outpatient setting. Increasingly, surgical procedures are taking place in doctors' offices, a trend driven in part by advances in minimally invasive surgical techniques that do not require a hospital stay.

As an internist who works in an outpatient setting herself, Dr. Bishop has witnessed the relative growth of outpatient compared to inpatient care: "We're treating more patients than ever, plus we're seeing sicker patients than we used to."

Implicit in the shift toward outpatient care is a commensurate challenge to reduce errors and ensure that patients benefit from the advanced treatments that are now widely available at private physician offices across the country. "Improving the safety of outpatient care will be difficult," says Dr. Lawrence Casalino, senior author of the study and chief of the Division of Outcomes and Effectiveness Research in the Department of Public Health at Weill Cornell Medical College. "But it is critical to the health of our patients that physicians and patient safety experts direct much more attention to this problem."

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