Although adverse events in inpatient settings are well-documented, less is known about patient safety in outpatient settings. In a new study published in the Annals of Internal Medicine, researchers found that 7% of patients experienced an adverse event in outpatient settings, with almost half occurring in physicians' offices. 

5 trends (re)shaping site-of-care shifts

Study details and key findings

For the study, researchers from Mass General Brigham conducted a retrospective review of adverse events from four healthcare systems in Massachusetts in 2018. In total, the researchers analyzed 3,103 EHRs from a random sample of patients aged 18 and older from 11 outpatient care facilities.

The study included seven nurse reviewers who identified potential adverse events through relevant triggers listed in the EHR data. Once a nurse flagged a potential adverse event, the information was sent to a physician adjudicator who determined whether it was an adverse event. The adjudicator then ranked the severity of the event, assessed whether it could have been prevented, and rated their confidence on a six-point scale.

Overall, the researchers found that 7% of patients experienced at least one adverse event while in an outpatient setting, and 1.9% of patients had at least one preventable adverse event. The most prevalent adverse events were adverse drug events (63.8%), healthcare-associated infections (14.8%), surgical/procedural adverse events (14.2%), patient care adverse events (8.3%), and perinatal/maternal adverse events (0.7%).

Almost half of the recorded adverse events occurred in a physician's office, with an adverse event occurring in one out of every 100 ambulatory encounters. For ED visits, there were around two adverse events for every 100 visits.

Older adults were also more likely to experience adverse events than younger ones. Among patients over 85 years old, 4.4% experienced serious adverse events, and 8.7% had preventable adverse events.

The researchers noted several limitations to the study, including the fact that some patient information may not have been recorded in the EHRs. The researchers also could not access relevant information from patients who had left the institutions where the study data was collected from.

Commentary

"While there have been calls to look at safety issues related to inpatient care, we need to examine outpatient care, too," said Luke Sato, one of the study's authors from the division of general internal medicine and primary care at Brigham and Women's Hospital and SVP and CMO at CRICO. "Healthcare organizations everywhere need to take the first step of measuring patient safety in both inpatient and outpatient settings. This work is groundbreaking, but it's also just the beginning."

Similarly, David Levine, one of the study's authors from the division of general internal medicine and primary care at Brigham and Women's Hospital, said the study is "an alarm bell" and that the data "highlights what is a national and international issue for patients."

"About 1-in-4 people every month are touched by outpatient care, yet we do not know enough about its safety," Levine said. "If we do not measure outpatient safety, we cannot start to improve care for all patients."

"Our results call for urgent measures to curtail outpatient harm," Levine added. "They also have the potential to help inform evidence-based interventions, pointing us to where change could be most effective to help protect patients and prevent adverse events from occurring."

Sebastian Beckmann, Advisory Board's managing director for quantitative insights, noted that key procedure volumes are continuing to shift toward lower-cost site-of-care, including outpatient settings. Although health systems have historically focused their operational improvement efforts on hospitals and inpatient pathways, Beckmann said that the study underscores the importance of taking a rigorous approach to safety, efficiency, and operation across different sites of care.

Nicholas Hula, a consultant with Advisory Board's life sciences, pharmacy, and diagnostics research team, added that while we need to have a rigorous approach to safety, we should also have a rigorous approach for measuring and reporting safety, as well as efficiency.

"This idea of safety is only going to get more important as we right-size resource use in order to operate in a more efficient ways," Hula said. "There are going to be less staff in the room, less supplies in the room, pressure to do cases faster, etc. That's 100% necessary for success, but we have to make sure it doesn't sacrifice safety[.]" (Lagasse, Healthcare Finance, 5/8; Mass General Brigham press release, 5/6; Levine et al., Annals of Internal Medicine, 5/7)

Advisory Board's 4 imperatives to ensure outpatient safety and quality 

By Nicholas Hula  and Sebastian Beckmann 

Volumes continue to shift to lower-cost settings like hospital outpatient departments, ambulatory surgery centers (ASCs), and physician offices. We predict total outpatient volumes will grow by 10.6% between 2023 and 2028, with much of that volume growth occurring in ASCs (9%) and office settings (10.7%).

While site-of-care shift trends aren't new, more services are moving to outpatient settings due to emerging technologies, increasing payer steerage, changing patient preferences, and evolving provider growth strategies. And it's not just simple and routine procedures that are experiencing volume growth in outpatient settings — it's also more complex cases like joint replacement, pacemaker implants, and spinal fusion.

Historically, health systems have focused most of their operational improvement efforts on inpatient pathways and sought to improve safety in that space. But as outpatient settings become more prominent sites of care delivery, it will be critical for organizations to take a rigorous approach to efficiency and safety there as well.

This imperative to ensure safety becomes even more crucial as outpatient sites seek to reduce the number of office or operating room supplies and staff to remain efficient and low-cost.

To ensure high quality and safety in outpatient sites, organizations should:

1. Maintain and practice emergency transfer protocols, especially as more complex services shift to non-hospital sites.
2. Hold office and other non-hospital sites to a high standard of cleanliness, beyond just office grade clean, to reduce infections.
3. Have a rigorous approach to patient selection that ensures patients go to the appropriate setting based on their level of complexity.
4. Above all, non-hospital outpatient sites must invest in their data collection capabilities to enhance the way they measure and report safety.

It's important for outpatient facilities to achieve and report a high level of safety and quality. This will help them communicate to other healthcare stakeholders that these sites provide safe, high-quality care and can serve as an appropriate setting to improve patient satisfaction and reduce healthcare costs.