In the United States, there are 30 times more outpatient visits as hospital discharges. As a result of the high volumes and complexities inherent to ambulatory settings, one in twenty patients can expect to experience a diagnostic error in their lifetime. According to the Agency for Healthcare Research and Quality, 55 percent of patients said that diagnostic errors were a chief concern to them.
Earlier this fall, ECRI Institute Patient Safety Organization took an in-depth look at patient safety events in ambulatory care, specifically physician practices and healthcare clinics. Nearly half of the 4,355 analyzed events were related to diagnostic testing. Errors that occur during diagnostic testing can have potentially devastating consequences for patients. The majority of these events occurred after tests had taken place, often due to a gap in communication.
For example, take a look at this case study from our PSO database:
A patient was seen for a urinary tract infection, and an antibiotic was prescribed while culture results were awaited. The culture showed Escherichia coli, which is resistant to the antibiotic the patient was taking; the prescribing physician ordered the current antibiotic to be discontinued, and an order for a new antibiotic was sent to the pharmacy. Because the patient had an account on the practice’s portal, the office sent her a message through the portal informing her of the result and providing new instructions. However…
Before we continue with this story, let’s clarify what the term diagnostic error actually means. The National Academies of Sciences, Engineering, and Medicine publication, Improving Diagnosis in Health Care, defines diagnostic errors as "the failure to establish an accurate and timely explanation of the patient's health problem(s) or communicate that explanation to the patient.”
Proper communication—not just among caregivers, but also between caregivers and patients—plays a crucial role in ensuring that patients receive the care they need, when they need it. Patients must be aware of when the test results will be received and how. Without feedback loops, communication may fail.
As our case study reveals, this is exactly what happened:
…the patient did not know how to access her portal and therefore did not receive the message, and continued taking the first antibiotic. The office later received a message from the emergency department stating that the patient had been admitted for sepsis resulting from pyelonephritis.
There was an assumption that the patient would access the portal for messages having to do with her lab results. If there had been a clear-cut process that ensured that the communication with the patient actually took place, this error could have been prevented.
Undoubtedly, there are many opportunities for missed communication all along the diagnostic testing continuum in ambulatory care settings. One quarter of the diagnostic testing events that ECRI analyzed in our Deep Dive on Safe Ambulatory Care occurred in the post-analytic phase of the diagnostic testing process. The majority of those events—82 percent—concerned inaccurate or missed reporting of test results, clear gaps in communication.
The question remains. What is it about ambulatory care settings that inherently leads to communication gaps?
Physician practices and healthcare clinics receive test results from many different labs and imaging centers. Those right results have to make their way to the right practice or care setting, and then to the right care provider. This process has to occur timely and accurately, so as not to delay diagnosis or care.
Taking a proactive approach to receiving diagnostic test results and communicating them to patients can help reduce the risk of test results falling through the cracks. Proactive strategies may include patient outreach to verify scheduling of testing and follow-up appointments; analyzing the laboratory testing process to identify weaknesses; and identifying best practices from organizations with low error rates and applying them to the organization.
Leveraging Health IT
Health IT systems support these strategies. When used correctly, health IT solutions can help track diagnostic tests by generating notices when tests, consultations, and referrals are ordered and results are received. It can produce alerts for critical test values, and prompt clinicians to review results and take necessary actions. Such technologies also have the potential to introduce errors, particularly if staff are not properly trained in their use or if alerts are not optimized. Cumbersome systems can result in the use of workarounds.
Simplifying and standardizing methods for complex processes reduces the risk of error because it reduces staff members’ reliance on memory and ensures that all members of the organization take the same safe steps to produce positive outcomes.
To learn more about the strategies for patient safety and risk reduction in ambulatory care settings, download the executive summary of ECRI Institute’s Deep Dive: Safe Ambulatory Care. Additional resources are available from ECRI Institute’s Partnership for Health IT Patient Safety.