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AHRQAmbulatoryCareInformationPDF.pdf
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Ambulatory Care Safety
September 7, 2019
Background
Despite the fact that the vast majority of health care takes place in the outpatient, or
ambulatory care, setting, e�orts to improve safety have mostly focused on the inpatient
setting. However, a body of research dedicated to patient safety in ambulatory care has
emerged over the past few years. These e�orts have identi�ed and characterized factors
that in�uence safety in o�ce practice, the types of errors commonly encountered in
ambulatory care, and potential strategies for improving ambulatory safety.
Factors In�uencing Safety in Ambulatory Care
Ensuring patient safety outside of the hospital setting poses unique challenges for
both providers and patients. A recent article proposed a model for patient safety in
chronic disease management, modi�ed from the original Chronic Care Model . This
model broadly encompasses three concepts that in�uence safety in ambulatory care:
The role of patient and caregiver behaviors
The role of provider–patient interactions
The role of the community and health system
Speci�c types of errors can be linked to each of these three concepts.
Types of Safety Events in Ambulatory Care
Since face-to-face interactions between providers and patients in the ambulatory setting
are limited and occur weeks to months apart, patients must assume a much greater role
in and responsibility for managing their own health. This elevates the importance of
including the patient as a partner and ensuring that patients understand their illnesses
and treatments. The need for outpatients to self-manage their own chronic diseases
requires that they monitor their symptoms and, in some cases, adjust their own lifestyle
or medications. For example, a patient with diabetes must measure her own blood
sugars and perhaps adjust her insulin dose based on blood sugar values and dietary
intake. A patient's inability or failure to perform such activities may compromise safety
in the short term and clinical outcomes in the long term. Patients must also understand
how and when to contact their caregivers outside of routine appointments, and they
must often play a role in ensuring their own care coordination (e.g., by keeping an
updated list of medications).
The nature of interactions between patients and providers—and between di�erent
providers—may also be a source of adverse events. Patients consistently voice concerns
about coordination of care, particularly when one patient sees multiple physicians, and
indeed communication between physicians in the outpatient setting is often suboptimal.
Poorly handled care transitions (e.g., when a patient is discharged from the hospital or
when care is transferred from one physician to another) also place patients at high risk
for preventable adverse events. When a clinician is not immediately available—for
example, after hours—patients may have to rely on telephone advice for acute illnesses,
an everyday practice that has its own inherent risks.
Underlying health system �aws have been documented to increase the risk for medical
errors, particularly medication errors and diagnostic errors, issues that are certainly
germane to ambulatory safety. Medication errors are very common in ambulatory care,
with one landmark study �nding that more than 4.5 million ambulatory care visits occur
every year due to adverse drug events. Likewise, prescribing errors are startlingly
common in ambulatory practice. Because the likelihood of a medication error is linked to
a patient's understanding of the indication, dosage schedule, proper administration, and
potential adverse e�ects, low health literacy and poor patient education contribute to
elevated error risk.
The fragmentation of ambulatory care in outpatient settings increases the challenge of
making a timely and accurate diagnosis. Indeed, a recent study estimated that 5% of
adults in the United States experience a missed or delayed diagnosis each year. Recent
data suggests that timely information availability and managing test results contribute to
delayed and missed diagnoses in outpatient care. Although use of electronic health
records in the ambulatory setting is growing, many practices still lack reliable systems
for following up on test results—a problem that has been implicated in missed and
delayed diagnoses.
Finally, while an increasing amount of attention has been devoted to measuring and
improving the culture of safety in acute care settings, less is known about safety culture
in o�ce practice. Burnout and work dissatisfaction, particularly among primary care
physicians, may adversely a�ect the quality of care. The AHRQ Medical O�ce Survey on
Patient Safety Culture is designed to assess safety culture in ambulatory care, and its
comparative database (which includes data from more than 900 participating practices)
is freely available from AHRQ.
Improving Safety in Ambulatory Care
Improving outpatient safety will require both structural reform of o�ce practice
functions as well as engagement of patients in their own safety. While EHRs hold great
promise for reducing medication errors and tracking test results, these systems have yet
to reach their full potential. Coordinating care between di�erent physicians remains a
signi�cant challenge, especially if the doctors do not work in the same o�ce or share
the same medical record system. E�orts are being made to increase use of EHRs in
ambulatory care, and physicians believe that use of EHRs leads to higher quality and
improved safety.
Patient engagement in outpatient safety involves two related concepts: �rst, educating
patients about their illnesses and medications, using methods that require patients to
demonstrate understanding (such as "teach-back"); and second, empowering patients
and caregivers to act as a safety "double-check" by providing access to advice and test
results and encouraging patients to ask questions about their care. Success has been
achieved in this area for patients taking high-risk medications, even in patients with low
health literacy at baseline.
Current Context
Although e�orts to improve safety have largely focused on hospital care, The Joint
Commission now publishes National Patient Safety Goals focused on ambulatory care.
The Agency for Healthcare Research and Quality is also leading e�orts to improve
ambulatory quality and safety through programs and research funding. A 2016 systematic
review commissioned by the World Health Organization identi�ed missed and delayed
diagnoses and medication errors as the chief safety priorities in ambulatory care, and it
highlighted the need to develop clear and consistent de�nitions for patient safety
incidents in primary care.
This project was funded under contract number 75Q80119C00004 from the Agency for
Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human
Services. The authors are solely responsible for this report’s contents, �ndings, and
conclusions, which do not necessarily represent the views of AHRQ. Readers should
not interpret any statement in this report as an o�cial position of AHRQ or of the U.S.
Department of Health and Human Services. None of the authors has any a�liation or
�nancial involvement that con�icts with the material presented in this report. View
AHRQ Disclaimers
Related Patient Safety Primers
Medication Reconciliation September 7, 2019
Culture of Safety September 7, 2019
Diagnostic Errors September 7, 2019
Editor's Picks
Medical O�ce Survey on Patient Safety Culture: 2014 User Comparative Database Report. June 25, 2014
Information exchange among physicians caring for the same patient in the community. December 3, 2008
Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire— Ambulatory Version. March 21, 2007
Adverse drug events in ambulatory care. March 6, 2005
View More
Related Resources
Patient Safety 101
September 7, 2019
Medication Reconciliation
September 7, 2019
Disclosure of Errors
September 7, 2019
Never Events
September 7, 2019
Rapid Response Systems
September 7, 2019
View More
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Ambulatory Care
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