The Safety of Outpatient Health Care : Review of Electronic Health Records.


Journal

Annals of internal medicine
ISSN: 1539-3704
Titre abrégé: Ann Intern Med
Pays: United States
ID NLM: 0372351

Informations de publication

Date de publication:
07 May 2024
Historique:
medline: 6 5 2024
pubmed: 6 5 2024
entrez: 6 5 2024
Statut: aheadofprint

Résumé

Despite considerable emphasis on delivering safe care, substantial patient harm occurs. Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited. To measure AEs in the outpatient setting. Retrospective review of the electronic health record (EHR). 11 outpatient sites in Massachusetts in 2018. 3103 patients who received outpatient care. Using a trigger method, nurse reviewers identified possible AEs and physicians adjudicated them, ranked severity, and assessed preventability. Generalized estimating equations were used to assess the association of having at least 1 AE with age, sex, race, and primary insurance. Variation in AE rates was analyzed across sites. The 3103 patients (mean age, 52 years) were more often female (59.8%), White (75.1%), English speakers (90.8%), and privately insured (70.4%) and had a mean of 4 outpatient encounters in 2018. Overall, 7.0% (95% CI, 4.6% to 9.3%) of patients had at least 1 AE (8.6 events per 100 patients annually). Adverse drug events were the most common AE (63.8%), followed by health care-associated infections (14.8%) and surgical or procedural events (14.2%). Severity was serious in 17.4% of AEs, life-threatening in 2.1%, and never fatal. Overall, 23.2% of AEs were preventable. Having at least 1 AE was less often associated with ages 18 to 44 years than with ages 65 to 84 years (standardized risk difference, -0.05 [CI, -0.09 to -0.02]) and more often associated with Black race than with Asian race (standardized risk difference, 0.09 [CI, 0.01 to 0.17]). Across study sites, 1.8% to 23.6% of patients had at least 1 AE and clinical category of AEs varied substantially. Retrospective EHR review may miss AEs. Outpatient harm was relatively common and often serious. Adverse drug events were most frequent. Rates were higher among older adults. Interventions to curtail outpatient harm are urgently needed. Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.

Sections du résumé

BACKGROUND UNASSIGNED
Despite considerable emphasis on delivering safe care, substantial patient harm occurs. Although most care occurs in the outpatient setting, knowledge of outpatient adverse events (AEs) remains limited.
OBJECTIVE UNASSIGNED
To measure AEs in the outpatient setting.
DESIGN UNASSIGNED
Retrospective review of the electronic health record (EHR).
SETTING UNASSIGNED
11 outpatient sites in Massachusetts in 2018.
PATIENTS UNASSIGNED
3103 patients who received outpatient care.
MEASUREMENTS UNASSIGNED
Using a trigger method, nurse reviewers identified possible AEs and physicians adjudicated them, ranked severity, and assessed preventability. Generalized estimating equations were used to assess the association of having at least 1 AE with age, sex, race, and primary insurance. Variation in AE rates was analyzed across sites.
RESULTS UNASSIGNED
The 3103 patients (mean age, 52 years) were more often female (59.8%), White (75.1%), English speakers (90.8%), and privately insured (70.4%) and had a mean of 4 outpatient encounters in 2018. Overall, 7.0% (95% CI, 4.6% to 9.3%) of patients had at least 1 AE (8.6 events per 100 patients annually). Adverse drug events were the most common AE (63.8%), followed by health care-associated infections (14.8%) and surgical or procedural events (14.2%). Severity was serious in 17.4% of AEs, life-threatening in 2.1%, and never fatal. Overall, 23.2% of AEs were preventable. Having at least 1 AE was less often associated with ages 18 to 44 years than with ages 65 to 84 years (standardized risk difference, -0.05 [CI, -0.09 to -0.02]) and more often associated with Black race than with Asian race (standardized risk difference, 0.09 [CI, 0.01 to 0.17]). Across study sites, 1.8% to 23.6% of patients had at least 1 AE and clinical category of AEs varied substantially.
LIMITATION UNASSIGNED
Retrospective EHR review may miss AEs.
CONCLUSION UNASSIGNED
Outpatient harm was relatively common and often serious. Adverse drug events were most frequent. Rates were higher among older adults. Interventions to curtail outpatient harm are urgently needed.
PRIMARY FUNDING SOURCE UNASSIGNED
Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.

Identifiants

pubmed: 38710086
doi: 10.7326/M23-2063
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Auteurs

David M Levine (DM)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.).

Ania Syrowatka (A)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.).

Hojjat Salmasian (H)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.).

David M Shahian (DM)

Harvard Medical School; Lawrence Center for Quality and Safety, Massachusetts General Hospital; and Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts (D.M.S.).

Stuart Lipsitz (S)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.).

Jonathan P Zebrowski (JP)

Harvard Medical School; Lawrence Center for Quality and Safety, Massachusetts General Hospital; and Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts (J.P.Z.).

Laura C Myers (LC)

Kaiser Permanente Northern California Division of Research, Oakland, California (L.C.M.).

Merranda S Logan (MS)

Harvard Medical School and Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts (M.S.L.).

Christopher G Roy (CG)

Maine Medical Center, Portland, Maine (C.G.R.).

Christine Iannaccone (C)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.).

Michelle L Frits (ML)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.).

Lynn A Volk (LA)

Mass General Brigham, Somerville, Massachusetts (L.A.V.).

Sevan Dulgarian (S)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.).

Mary G Amato (MG)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (C.I., M.L.F., S.D., M.G.A.).

Heba H Edrees (HH)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (D.M.L., A.S., H.S., S.L., H.H.E.).

Luke Sato (L)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School; and CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (L.S.).

Patricia Folcarelli (P)

CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (P.F., J.S.E., M.E.R.).

Jonathan S Einbinder (JS)

CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (P.F., J.S.E., M.E.R.).

Mark E Reynolds (ME)

CRICO and the Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts (P.F., J.S.E., M.E.R.).

Elizabeth Mort (E)

Harvard Medical School; Lawrence Center for Quality and Safety, Massachusetts General Hospital; Division of General Internal Medicine, Massachusetts General Hospital; and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (E.M.).

David W Bates (DW)

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School; and Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (D.W.B.).

Classifications MeSH