Thinking about Patient Safety for Chronically Ill Outpatients

• 7/2/2009
• Author: Steven Berman
• Category: The Journal Blog
• 11954 Views
• 0 Comments
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This week, Urmimala Sarkar, the lead author of “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care,” which appears in the July 2009 issue, guests on the Journal blog. She reflects on the origins of the article and on the need to engage patients, especially the large population of patients with chronic conditions, in improving safety. Dr. Sarkar and I welcome your own reactions.

While most prior research has focused on patient safety in the hospital setting—that is, medical errors during hospital stays—we argue in our article that more attention should be paid to ambulatory populations with chronic diseases. Unlike acute care settings, where patients receive care from trained teams of clinicians guided by protocols, the outpatient setting involves patients performing the day-to-day management of their chronic conditions themselves.

I started thinking about these issues during my training. As a resident, I saw a new patient in my primary care clinic, just discharged from the hospital, and found that she was taking literally four times the maximum dose of her blood pressure medication, an ACE inhibitor. There were a host of factors at work. For one thing, there was a formulary change at our health system, so she had two different medicines from the same class. One should have replaced the other, but that was not communicated to her. Then, when she was discharged from the hospital, she was given an entirely new set of medicines, but she did not realize she should stop the medications she had at home. When she came to see me, she was clearly overwhelmed and unable to name her medications or describe her regimen. After I pieced it together, I sent her for blood tests, which showed new kidney failure from the medication overdose. I had to send her right back to the hospital. This example highlights some of the problems that we tried to touch on in article—transitions in care, inadequate communication between providers, and limited health literacy—all leading to medication confusion. 

As a primary care provider myself, I think it’s crucial to keep in mind how complex our patients’ interactions with the health care system are. I don’t think it’s coincidental that current patient safety efforts focus more on inpatient issues. The issues raised in the ambulatory setting are much less amenable to any “quick fix” by providers, administrators, or even accreditors. For outpatient chronic disease safety, we need to engage patients to improve safety, and we still have a lot to learn about how to do that.