Back in 2000, a group of experts convened by the Agency for Healthcare Research and Quality (AHRQ) reported that, although substantial medical error and injury was occurring in the ambulatory setting, very little research had been done to understand the reasons why.

To address what they recognized as a serious issue, this expert panel made 11 specific recommendations that were intended to stimulate research in this area.

Fast forward to the present and, as with so many quality improvement efforts, almost none of these recommendations have been implemented and the problem persists.

Why does this matter?

A disproportionately high – and still growing – number of Americans receive medical care in ambulatory settings. According to the American Medical Association, 300 people are seen in ambulatory settings for every person admitted to a hospital.

Because hospitalized patients remain in that setting over a period of time, there is a relatively large window of opportunity for identifying, investigating, and attributing the causes of medical errors and near misses.

In contrast, patient visits to a broadening range of widely dispersed ambulatory settings are brief, and medical errors such as an incorrect medication or dosage may go undetected for long periods of time.

Why has it taken so long for us to focus on ambulatory quality and safety?

Hospitals employ risk managers, compliance officers, and chief quality officers to assure that rules are set and followed – but no such infrastructure exists in most ambulatory settings.

Interestingly, the urgent need for patient safety measures in the ambulatory setting was amplified by a recent study of outpatient malpractice claims.

Looking at paid malpractice claims for 2009, the authors found that 4,910 were for outpatient care compared with 4,448 for inpatient care, a clear indication that malpractice risk is an under-recognized issue.

Although the total payment was higher for inpatient claims ($362,965) than outpatient ($290,111), the outpatient claims were far from trivial – with major injury or death accounting for two-thirds of the events.

In the outpatient setting, the most common types of adverse events associated with paid claims were classified as diagnostic (45.9%), treatment (29.5%), and surgical (14.4%).

After what is being called a “lost decade in ambulatory safety,” Matthew K. Wynia, MD, MPH, and David C. Classen, MD, MS, published a commentary that calls for a refocused national agenda and adoption of five core aims for improving ambulatory patient safety.

I’ll summarize these aims briefly:

1. Conduct a large national study on the epidemiology of ambulatory patient safety using accepted tools to screen for errors and chart reviews to detect harm in large ambulatory care clinics.
2. Identify and pursue an early and easily achievable goal, such as timely follow-up of abnormal test results.
3. Engage patients, their families, and community organizations in ambulatory safety improvement efforts.
4. Link the ambulatory safety agenda to high-profile inpatient safety initiatives; e.g., in concert with the initiative for reducing hospital readmissions, emphasize and study the role of ambulatory care clinicians in ensuring patient safety before, during, and after hospitalizations.
5. Foster the development of a national system of clinics and practices that function as ambulatory safety “laboratories.”

As in all things, money talks, and a report that AHRQ has dedicated $74 million for research in ambulatory quality and safety through health information technology is a clear indication that this important issue is finally being taken seriously.

The bottom line is that improving ambulatory quality safety should matter a great deal to all of us, and I’m hopeful that progress will be made toward that end in the coming decade.

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

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