The Universal Challenge

Edition: April 2009 - Vol 17 Number 04
Article#: 3167
Author: Repertoire

In 1999, patient safety became something of a cause célèbre among healthcare providers and patient advocates. That was the year that the Institute of Medicine published its infamous “To Err Is Human” report, suggesting that as many as 98,000 hospital patients die each year from medical errors. Since then, providers have been working hard to clean up their act. Indeed, 90 percent or more of the 1,466 hospitals that received Joint Commission accreditation surveys during 2007 demonstrated compliance with 11 of the 18 requirements of the organization’s 2007 National Patient Safety Goals.

But in the ambulatory setting, such as physicians’ offices, ensuring the safety of patients is proving to be a bit more elusive. And it is beginning to catch the attention of the public. In January of this year, the Association for Professionals in Infection Control and Epidemiology (APIC) issued a statement sounding the alarm about unsafe injection practices in ambulatory care settings. Citing a study in the Annals of Internal Medicine, APIC CEO Kathy Warye pointed out that 33 outbreaks of hepatitis B or C virus infection caused by unsafe injection practices in U.S. outpatient healthcare settings had occurred during the prior 10-year period. “This comes on the heels of a highly publicized outbreak in Nevada in which 40,000 people were notified of their possible risk of hepatitis C due to improper use of syringes at a Las Vegas endoscopy clinic,” Warye said. “These outbreaks were preventable and should never have occurred.”

Then, citing information from the Centers for Disease Control and Prevention, The Wall Street Journal reported on Feb. 4, 2009, in an article entitled “Lax Needle Use in Clinics Raises Alarm,” that unsafe injection practices are one of the leading causes of infections in doctors’ offices, outpatient clinics and long-term-care facilities. “Although most healthcare workers are aware of the dangers of reusing needles, other injection guidelines aren’t always followed, including disposing of syringes after each use,” according to the article. “Contaminated shots can lead to transmission of such diseases as hepatitis and HIV, along with other viral and bacterial infections.”

All over the place

“What makes the ambulatory setting so challenging is that it’s all over the place,” says Richard Roberts, MD, JD, professor of family medicine at the University of Wisconsin Medical School in Madison and a practicing family physician. “Solo practices still make up 20 to 25 percent of primary care doctors.”

Roberts is a past president of the American Academy of Family Physicians, president-elect of the World Organization of Family Doctors, and a member of the board of governors of the National Patient Safety Foundation. Last fall, he participated in a Web conference on “Engaging Physician Practices in Patient Safety and Risk Management: Strategies for Healthcare Systems,” sponsored by ECRI Institute, Plymouth Meeting, Pa.

His interest in patient safety and risk management goes way back, even before he became a doctor. He started his professional life as a young lawyer, working in the Carter White House in Washington. Early on, he was exposed to malpractice and risk management issues. He developed an interest in quality improvement and guidelines, then practice and systems redesign. “Patient safety has been a very large part of that,” he says.

What many people fail to understand is that while hospitals do indeed present a variety of safety-related risks to patients, far more care is delivered in the doctor’s office, says Roberts. “The place that care most often happens is the 2-to-3-doctor family physician practice,” he points out. Of the 1.1 billion doctor visits that occur each year in the United States, a person is 30 times more likely to be seen in a doctor’s office than in a hospital.

From a patient-safety perspective, that is definitely a mixed bag.

Mixed bag

Says Roberts, “The nice thing about the hospital for the patient-safety aficionado is this: It is a much more confined and focused environment, where there are clear leadership chains of command.” In the acute-care setting, safety policies can be implemented and reinforced. Physicians’ offices, on the other hand, are more informal and flexible. “Their practice systems may not be as well articulated … as those of hospitals.”

On the other hand, one could argue that doctors’ offices are more patient-sensitive than hospitals, whose staffs care for hundreds or thousands of patients every day. Because they operate on a smaller scale, doctors’ offices experience fewer handoffs of patients from one caregiver to another. “And half the errors occur when you hand the care off to somebody else,” points out Roberts.

Doctors’ offices have one more thing going for them. “If you have chest pain today and go to the ER, there’s a 90 percent chance you’ll land in a hospital bed,” says Roberts. “But in my practice, I know you as a person, we have a relationship, and I know it’s your stomach acid kicking up again.”

The flip side is that the family doctor can become inured to what he or she sees. Hence, the doctor might dismiss a long-time patient who presents with chest pains. “There’s so-and-so, with his stomach acid again,” when in fact, the patient might have a serious problem. “If you’re doing a good job, you’re mindful of that,” says Roberts. “I tell my residents, ‘Even if you know the patients, approach them with a fresh set of eyes.’”

What’s more, despite the fact that patient volume is lower at the doctor’s office than in the hospital, the typical family doctor can still “touch” as many as 130 to 150 patients a day, either in person, on the phone, through emails or consultations with other doctors, says Roberts. “There’s a constant swirl of chaos, and it’s easy for things to get lost.” Test results can go unreported, for example. The challenge for the doctor is to encourage his or her patients to become fully engaged in their own care. That might mean questioning the doctor’s judgment or prescribed course of action, bringing in medical articles from the Internet, and most important, following up on such things as lab tests.

“A fair chunk of patients are like car owners who take their car to the shop and tell the guy, ‘I’ll be at the Starbucks; call me when you’re done,’” says Roberts. “That’s how people think about their body. You have to get them engaged.”

Patients engaged in their care

Like Roberts, Kathleen Shostek, RN, senior risk management analyst for ECRI Institute, stresses the importance of patient involvement in helping improve patient safety and prevent errors. In the typical practice, there’s precious little time for providers to adequately educate their patients and answer their questions about medications, their condition and their treatment plan, she says. “It takes an enormous amount of effort to meet the patient at his or her level of understanding and to get them involved in their own care. Offices need to develop systems to support them in this effort.”

Though Shostek began her medical career in the clinical aspect of nursing, she switched to risk management following a liability suit involving the hospital where she worked. “I knew we were giving good care, and the healthcare team cared about patients,” she says. “Unfortunately, the systems don’t always support their efforts, and patients are harmed.”

Twenty years ago, the term “patient safety” wasn’t readily used, she says. “Then, [it was an issue primarily of] avoiding malpractice suits and mitigating financial losses.” Since the Institute of Medicine report, however, caregivers have looked more critically at how they provide care, says Shostek. “A tremendous amount of work has been done, and we’re beginning to see positive changes. Safety is now at the forefront, from leadership to front-line caregivers.”

That extends to the physician office as well, and with good reason, says Shostek. “Eighty percent of all non-hospital care is provided in the physician’s office, and in about one of every four doctor’s office visits, errors and preventable events occur. That’s a huge opportunity for physicians to learn from treatment errors.”

Physicians and their staff have made strides in improving the diagnostic process, traditionally the area of most concern in doctors’ offices, says Shostek. “You see clinical prompts and protocols … that help them keep track of diagnostic tests and referrals.” For example, if a patient gets a referral for a colonoscopy, did she in fact have it? If so, did the physician get the results? If so, did he or she communicate them to the patient? And if that patient needs follow-up care, did the physician track whether she received it?

“You have to close the communication loop,” says Shostek. “‘No news is good news’ is often how lab tests are handled.” That’s not good enough anymore.

It’s true that physician practices that are affiliated with larger health systems have access to information, expertise and support systems that independent practices do not, says Shostek. They can draw on the hospital’s clinical engineering department or infection control professionals. But the fact is, some processes that work well in the acute-care setting don’t translate to ambulatory care. “There’s not a lot of research to say that the same systems in place in hospitals will work in physicians’ offices,” she says.

But the biggest challenge facing a physician practice – any physician practice – isn’t lack of concern or systems. It’s lack of training and even more, a lack of time. “Physicians and office staff have so many competing demands. Patient safety isn’t top of mind,” says Shostek.

For patient safety to take hold in the office, it has to permeate the culture of the practice, she adds. “Practice leaders – clinicians and office managers – may need to see the business case before making changes. But once they do, they’re usually on board.”

National Patient Safety Goals

The Joint Commission’s 2009 National Patient Safety Goals for ambulatory care are the following:

• Improve the accuracy of patient identification.

• Improve the effectiveness of communication among caregivers.

• Improve the safety of using medications.

• Reduce the risk of healthcare-associated infections.

• Accurately and completely reconcile medications across the continuum of care.

• Reduce the risk of patient harm resulting from falls.

• Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.

• Reduce the risk of surgical fires.

• Encourage patients’ active involvement in their own care as a patient safety strategy.

• Prevent healthcare-associated pressure ulcers.

• Identify safety risks inherent in its patient population.

• Improve recognition and response to changes in a patient’s condition.

Source: Joint Commission

PSOs offer safe havens to doctors

In the past, physicians feared reporting mistakes they had made for fear of malpractice suits. Not only did patients suffer because of their silence, but doctors and their staffs lost the opportunity to learn from their mistakes. But today, physicians have an outlet that allows them to report errors without fear of retribution.

On Jan. 19, 2009, the final rules went into effect regarding the Patient Safety and Quality Improvement Act of 2005. The Act authorized the creation of Patient Safety Organizations, or PSOs, to collect and disseminate (on an aggregate basis) information about mistakes and medical errors. The Agency for Healthcare Research and Quality (AHRQ) administers the provisions of the Patient Safety Act, and is responsible for maintaining a list of those entities whose PSO certifications have been accepted in accordance with the law. However, even though PSOs were set up by federal legislation, the government is not involved in either the collecting or dissemination of data.

In the past, individual facilities and states have encouraged clinicians to report patient safety events, points out AHRQ in its Web site. But two major impediments have stood in the way of collecting enough representative data to make significant improvement:

• Fear of disclosure. Physicians and other clinicians have been reluctant to participate in peer review of patient safety events for fear of legal liability, professional sanctions, or injury to their reputations.

• Isolated data. Patient safety event reports traditionally have not been standardized to allow aggregation of data and sharing across different institutions. An insufficient number of reports have made it difficult to identify and mitigate underlying patterns of causal factors.

As of mid-January, 39 PSOs were in place and ready to accept information. For a list of AHRQ-approved PSOs, go to

Free online tools help physician practices improve patient safety

Sales reps might suggest that their physician customers download a series of Web-based tools aimed at increasing awareness, knowledge and implementation of best practices to reduce the risk of patient harm in physician practices. The tools, Pathways for Patient Safety™, can be downloaded free at They were released recently by the Health Research and Educational Trust, the Institute for Safe Medication Practices and the Medical Group Management Association.

The modules, which can be used singly or as a set, are:

• “Working as a Team,” which outlines actions required to build high-performing patient safety teams and techniques for effective communication among caregivers and with patients to reduce patient harm.

• “Assessing Where You Stand,” which provides practical steps to minimize medical errors by assessing current patient-safety procedures, addressing practice culture and setting goals.

• “Creating Medication Safety,” which describes factors practices should consider when implementing or augmenting a medication reconciliation process, and when prescribing or administering medications.

The modules are said to combine step-by-step instructions with templates and additional resources. Tool content is based on findings of a 2006 patient safety self-assessment of medical groups, input from an expert panel, and feedback from a representative group of pilot practices that reviewed the tools.

The Pathways for Patient Safety series builds on an earlier effort by the three organizations. In 2006, they launched the Physician Practice Patient Safety Assessment® (PPPSA), a self-assessment tool that helps physician practices evaluate their patient safety processes and detect areas for improvement. The PPPSA covers 79 areas related to medication safety, patient handoffs and transitions, practice management and culture, and related topics.