MARIA CASTELLUCCI October 23, 2019
Diagnostic errors are the most frequent adverse
safety event patients can experience in outpatient care, according to a new ECRI Institute report.
The analysis, published Wednesday, found that
diagnostic testing errors represented 47% of all patient safety events reported
in an outpatient setting over a one-year period. The second-most common safety
event was medication errors, accounting for 27% of total events.
Considering the volume of testing performed in
the ambulatory setting and the complexity of the process, it's not surprising
it's the most common mistake that happens in outpatient care, said Carol Clark,
acting associate director of the ECRI Institute Patient Safety Organization.
Diagnostic testing has many phases including ordering
the appropriate test, gathering and delivering the sample appropriately and
interpreting the results. Additionally, about 40% of all primary-care office visits involve
some medical test.
"There's a lot of opportunity for
errors," Clark said.
The report says 4,355 adverse events were
voluntarily reported from December 2017 to November 2018. Providers submit
adverse events to the ECRI Institute as part of their participation in its
patient safety organization. More than 1,800 providers are part of the
organization and 3 million adverse events overall have been reported.
The report included data from ambulatory care
centers, community health centers and physician practices. Ambulatory surgery
centers were excluded from the analysis because they don't provide comparable
services.
In its report, ECRI recommended providers
establish a chain of command for communicating test results and use technology
to track test results and ensure follow-up, among other practices that could
prevent diagnostic errors.
Even with the recommendations, Clark said there
is "no magic bullet" to preventing diagnostic errors. Solutions are
likely unique to the practice and their resources.
There is more momentum recently to address diagnostic errors. The
Society to Improve Diagnosis in Medicine has gathered stakeholders from across
the country to enhance research and encourage greater attention from providers
on the problem.
Society CEO Paul Epner said previous studies
correlate with ECRI's findings that diagnostic mistakes are the most common
medical errors in healthcare. Although he added that ambulatory settings have
more complexities to deal with than acute settings, making the errors
particularly challenging to prevent. Usually outpatient settings don't have
labs in-house so they have to send off their samples, leaving room for samples
to be mishandled or results to never get back to the doctor.
In terms of medication errors, most were caused
by giving the patient the wrong drug, the report found.
Clark said this can occur because centers
haven't implemented processes to ensure the right medications go to the correct
patient. It can be an issue of how the medications are stored or the training
of the personnel who distribute it. Medical assistants typically administer medications
now rather than nurses and sometimes they aren't appropriately trained, she
said.
The second-most common reason for a medication
error involves ordering or administering treatments that trigger allergies or
adverse reactions. It's particularly hard to prevent those errors in outpatient
care because they typically don't have a complete medical history of the
patient, Clark said. Incompatible electronic health records usually mean
outpatient providers aren't aware of all medicines a patient is on. Reconciliation
and thorough patient assessments are vital to prevent medication errors, Clark
said.
Falls were the third most frequent adverse event
reported during the period, accounting for 14% of total events.
Falls are likely common because most patients who
see their physician frequently are elderly or have comorbidities, which can
make them weak, frail or disoriented, Clark said.
One way to prevent falls is to screen the
patient for fall risk during the initial assessment, according to the report.
Although it only represented 5% of the total
events, security issues were addressed in the report.
Workplace violence is a well-known problem in
healthcare, and clinicians who work in ambulatory care are particularly
vulnerable because they lack the security and robust personnel that acute-care
settings have, Clark said. She expects incidents are significantly
underreported because many clinicians are so used to the conditions, but it can
impact quality of care and contribute to burnout.
The report recommends doing risk assessments to
evaluate potential opportunities for violence, provide staff with tools to
recognize cues for combative behavior and train staff on how to deal with
aggressive situations.
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