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Thinking Outside the Hospital: A Call to Action for Outpatient Safety

Blood glucose test

Health care has been thinking about medical errors for nearly 20 years, starting with the Institute of Medicine’s 1999 report “To Err is Human.” This and other work across the country have correctly shed light upon such medical errors as amputation of the wrong limb, inpatient adverse drug events and hospital-acquired infections, and we have made great strides in preventing these errors. However, most patient care occurs outside of the hospital, and little attention has been paid to identifying and addressing patient safety in this setting.

While there is not much evidence on preventable harm outside the hospital, this is more a reflection of the absence of research rather than an absence of risk. Patient safety errors do occur in the outpatient setting, so our focus on safety must broaden to include this important segment of care.

A Chronic Disease Example

The management of people with diabetes perfectly illustrates the dangers that some patients face in the ambulatory setting — and the great impact that improving care for these patients might have. Diabetes affects 21.9 million adults in the U.S. It causes few obvious symptoms, and roughly 8 million people are unaware that they even have diabetes. This chronic disease is the No. 1 cause of blindness, kidney disease requiring dialysis and limb amputation not related to trauma in U.S. adults.

In the best and most common circumstances, the majority of diabetes care occurs outside the hospital. Patients self-monitor, typically checking their own blood tests and changing their medication doses based upon the results. They should receive routine care, such as annual diabetic eye exams and twice-yearly lab testing to monitor trends in blood sugar control.

There are at least seven commonly used classes of medications used to treat diabetes, and each has different side effects. These require regular monitoring, including lab testing, by a health care provider. One side effect of many of these medications is hypoglycemia, which can cause patients to become unresponsive, have seizures and possibly die.

Given these safety risks, wouldn’t it seem that obtaining a timely diagnosis, ensuring that each patient receives the basic recommended care, appropriate medication monitoring, and good teamwork and communication across care providers should be at the top of our minds, with robust processes in place to avoid common mistakes and missed care? Wouldn’t we want to treat these hazards as seriously as we treat those in the hospital?

Jane Smith: A Case Study

Let’s consider a typical patient with diabetes: Jane Smith is a 62-year-old woman who has had diabetes for 20 years and had a stroke five years ago. The stroke has left her with weakness on her left side, and her diabetes has led to vision loss, so she depends upon her children to drive her to medical appointments two hours away. Similar to many people with diabetes, she is on medications for multiple medical conditions, including two medications for high blood pressure, one medication for cholesterol, two medications for diabetes and one medication for diabetic neuropathy. Her insurance does not pay for insulin pens, so she draws her insulin from a vial to a syringe four times a day to control her blood sugar.

It is hard for Smith to ensure an accurate insulin dose in the syringe due to poor vision. She hasn’t seen anyone for her poor vision in three years, even though this exam is indicated yearly, because she isn’t aware of this recommendation. During her appointments, her care providers don’t usually get to this recommendation because of other medical issues that arise. The last time she was seen by her primary care doctor, she noted that her glucose control, measured by her hemoglobin A1c, was “good.” The goal for most people with diabetes is to have an HbA1c of <7 percent, and hers was 6.8 percent. Smith left the appointment feeling positive about her diabetes.

Unfortunately, Smith’s primary care doctor did not get to review her glucose readings because the medical office did not have the ability to download the readings from her testing device. If it had, the physician likely would have noticed that Smith was frequently having low blood sugar before dinner and should have adjusted her lunchtime dose of insulin downward. The sad reality: Smith was not receiving the simple diabetes recommendations — like a yearly eye and foot exam — and she was having frequent hypoglycemic events due to a high lunchtime insulin dose. This made her glucose control by HbA1c look “good.” Often, people who have had diabetes for a long time stop having symptoms of low blood sugar, but that doesn’t mean that the low blood sugar isn’t dangerous. In fact, low blood sugar, or hypoglycemia, can cause seizures, unresponsiveness and death.

A few months after the primary care doctor visit, Smith did suffer a hypoglycemic event that resulted in her death. Unfortunately, there was no investigation done due to her advanced age, and her hypoglycemia was not considered an adverse event that could have been prevented. Without an investigation of the event, there was no opportunity to identify strategies and principles to improve the health care system, including possible improvements in care coordination and patient-provider communication.

Filling in the Gaps

In our example, many aspects of Smith’s care should be considered safety issues. She did not have easy access to specialists to help her maintain her diabetes. Her primary care doctor was unable to ensure that Smith received all recommended care for her diabetes because the office lacked the technology to track and improve care with respect to these important measures. The lack of office glucometer-reading software led to the patient’s misinterpretation that her HbA1c reflected “good” blood sugar levels, instead of the dangerous hypoglycemic events that would take her life. As a result, no changes were made to her insulin regimen; this directly led to her death.

Lack of awareness of these events does not make outpatient care less risky than its inpatient counterpart. Outpatient care providers must develop lenses with which to identify, analyze and mitigate errors that are prevalent in this setting. We must be clear that a lack of awareness does not equate to a lack of risk, and we must work together to reduce risks wherever health care occurs.

This post is adapted from Arkansas Hospitals, a publication of the Arkansas Hospital Association, Little Rock, Arkansas.



Nisa Maruthur and Melinda Sawyer

Nisa Maruthur, M.D., M.H.S., is an assistant professor of medicine and epidemiology at the Johns Hopkins University School of Medicine. She co-directs the Johns Hopkins General Internal Medicine Fellowship and is an active member of the Comprehensive Unit-based Safety Program team in an outpatient practice. Melinda Sawyer, M.S.N., R.N., C.N.S.-B.C. is assistant director of patient safety for the Armstrong Institute and The Johns Hopkins Hospital. She also directs the institute's learning and development programs.

7 thoughts on “Thinking Outside the Hospital: A Call to Action for Outpatient Safety”

  1. I appreciate tremendously the need to address the outpatient part of patient care. As we move closer to Pay for Performance model of reimbursement healthcare field at large will have to take a second look at this problem. Another interesting example ( I specialize in outpatient fall prevention) can be the lack of medical follow up for patients at high risk of falls in hospital. Our current model of care is once we identify that patients are at high risk of falls in hospital we take measures (e.g. Falls Risk sign, yellow non-slip socks, PT eval) to address the issue, and perhaps even recommend outpatient PT follow up, but this is often insufficient, for per CDC STEADI guidelines there need to be significant physician involvement in fall prevention, but most physicians have never been officially trained in fall prevention (though syncope work up was usually well covered), so neither do inpatient providers provide a comprehensive fall prevention physician driven protocol nor do we have a large number of outpatient physician providers trained to address this issue (though geriatricians and PMR providers are probably best trained to address this issue). I would love to reach out to the community and see if there are others interested in developing a community of providers (physicians, nurses, therapists, etc...) interested in the post-discharge continuum of patient care.

    1. Hey Ive been working in the healthcare field for over 10 years. At the moment I work in an inpatient hospital pharmacy while also working in a well known insurance company initiating Prior Authorizations for prescription medications. I'm working on a project to coordinate care after discharge to reduce hospital readmissions. If your interested shoot me an email.

  2. Pingback: American Data Network | Stories You Need: Bringing Back House Calls, Outpatient Safety

  3. When our Mom came home from the Hospital she had 8 pills a day. She took 5 in the Morning and then the last three before she went to bed at night. Our doctor told her to use a AM PM pill box. It didn't work for her. She kept double dosing. We got her this new smart pill box that has alarms and lights up the compartment she needs to take. It is keeping her at home. We think it is great. It is our way of thinking outside the box

  4. Help patients by allocating for presplit tabs and prepackaged insulin. We may never know if inaccurate administration contributes to risk. The system is so broken and the resources so siloed it is disgraceful.
    Help patients to be better informed about what it means to participant in there care. Some already do, some do so misguidedly, some don't and some won't.

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