Dr. Jon Hallberg: New attention on reducing errors in outpatient procedures

The attention paid over the past decade to reducing medical errors in the hospital setting has reduced deaths, infections and injuries caused by other surgical and hospital errors — and now there's a call for similar attention on outpatient procedures.

A review by the American Medical Association Center for Patient Safety found limited research of outpatient safety issues. The organization detailed their findings in a December 2011 report.

"We still know very little about patient safety in the ambulatory setting, and next to nothing about how to improve it," the report read.

MPR medical analyst Dr. Jon Hallberg discussed the report with MPR's Tom Crann this week. Hallberg is a physician in family medicine at the University of Minnesota and director of the Mill City Clinic.

An edited transcript of that discussion is below.

Tom Crann: I know it may seem simple here, but let's lay out the difference between inpatient and outpatient or ambulatory care, as it's sometimes called.

Dr. Jon Hallberg: Well, I think it's as simple as this — that if you are inpatient, you are staying overnight. That's really the bottom line difference there. Ambulatory implies that you walk in and you walk out. So it's a same-day situation.

Crann: Okay. Now there are a lot more clinical visits than hospital stays on a regular basis. That's the way we interface with the medical system, usually in a clinic visit, whatever that is.

Hallberg: That's right.

Crann: So give us an example of the numbers.

Hallberg: Well, they estimate there's something like a 300-to-1 ratio — that 300 people will go to an outpatient setting versus an overnight stay. So the vast majority of our interaction with the health care system is that same-day situation.

Crann: And have the guidelines and protocols and procedures for clinics been as strict as they are in hospital settings?

Hallberg: Not at all. This is really where this is coming from. They looked at ten years of data, and they found that, you know, it's almost like a lost decade — that there was so much focus on what happens in the hospital setting — reducing "never events," that people cannot die, they can't have the wrong part of the body operated on — that we've just sort of forgotten that there's this huge interaction with health care that has been not really looked at.

Crann: Now the tracking of hospital errors and the accountability — it's been tracked and made public pretty closely these days in the last few years, but given the volume here of outpatient visits, do we have a good sense of how often errors are happening?

Hallberg: Not at all. In fact, when all of this really became apparent in 1999 when the first study came out looking at these awful events that could happen potentially in hospitals, it was all over the news. And now they're sort of saying... that we just don't have a firm sense of how many people might be dying, for example, from medical errors. So this is a brand new area that's being looked at, and the AMA commissioned a study that looked at dozens of studies over the last decade to try and get a handle on this.

Crann: In a hospital setting, you're talking about operating on the wrong leg or something like that, but what kinds of things are we talking about here in the clinic, for example, what kinds of errors?

Hallberg: They broke it down to the top six errors, as far as categories, and they go from medication errors, such as prescribing the wrong medication or the wrong dose, diagnostic errors, simply making the wrong diagnosis, laboratory errors — for example, getting a critical lab value back and not conveying that to a patient — and frankly, not having the right clinical knowledge for a problem, and then looking at communication issues and administration problems.

Crann: Are there recommendations in this report about ways to address these errors?

Hallberg: No, not yet. So this is a little unusual in the sense that I think they're just sort of stating the case that there is a problem or no doubt that there is some kind of a problem, but we really need now to address it (and look at) how are we going to remedy some of this.

Crann: In your experience, can you point to some examples of good procedures that are in place and are working?

Hallberg: I can think of one great example that takes sort of a laboratory issue and a medication issue and combines them. Many, many people are on a drug called Coumadin or warfarin. It's a blood thinner. And people who have had heart valves replaced or they have an irregular heartbeat, this medication prevents clots from forming. And it's truly life saving, but at the same time, it can make the blood too unsticky, too thin, and that can result in problems. So it has to be monitored very, very carefully. And for years, doctors' offices were responsible themselves for monitoring this. It was a total sort of by the skin of your teeth, gut feeling kind of 'how do you adjust the meds?'

A few years ago, we put a combined group together and we have a Coumadin clinic now through Fairview and the University (of Minnesota). Any one of my patients who's on this medication goes through that. I know that by having pharmacists, people who really understand the nature of this medication, that their actions have saved lives. And I think that's a great example of where we need to do more of that kind of thing in the outpatient or clinic setting.

(Interview edited and transcribed by MPR reporter Madeleine Baran)

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