Patient safety in outpatients: What are the gaps in measuring and reporting harm?

Summary

This blog is part of a series in which NHS rheumatology consultants Anne Kinderlerer and Benjamin Ellis highlight some of the key patient safety risks in outpatients and look at why these issues have been neglected by health systems. 

Anne and Benjamin identify key gaps in our knowledge about errors and adverse events associated with outpatient care. They outline the need for more research, data and improvement focus relating to:

• transfers of care
• referrals
• review and prioritisation of patients on waiting lists
• medication errors
• investigation and result tracking.

Content

In our introductory blog, we looked at the reasons why patient safety in outpatients doesn’t receive as much attention as patient safety in inpatient settings. Now we will look at the result of this lack of attention, which is that we don’t know enough about the nature, prevalence and severity of harm and near misses in outpatient departments. If we are going to reduce outpatient harm, we first need to identify and define what we don’t know about adverse events that happen in outpatients. 

What do we know about harm in outpatients?

There have been very few attempts to categorise the types of errors that happen in outpatients. For example, the recent SafeCare Study looked at electronic health records in Mass General Brigham health system in the US, and a sub study of this looked at outpatient errors. The results showed a significant level of harm experienced in outpatients—it found that 7% of patients experienced at least one adverse event, and 17.4% of these adverse events were considered serious in nature.[1] So researchers are beginning to uncover what harm looks like in outpatient settings, but we need much more data and analysis to really understand the issues. 

What are the knowledge gaps?

Errors during transfers (or ‘handoffs’) of care 

One of the common places where errors occur is in transfers of care, which are more frequent in outpatients than we think.

• There's the original transition from primary to secondary care which is fundamental to most outpatient appointments. 
• Then there are transfers between hospital specialties to assess whether a patient needs to be seen and we either do that directly or via primary care.
• Every time a doctor refers somebody for an investigation, that's also a transition.
• The booking of a future appointment to continue care, or rebooking an appointment following non-attendance, can also be understood as a transfer between episodes of care.
• There’s also the handoff that happens when the patient is seen by different healthcare professionals within the same service. 
• One that is often forgotten is when we transfer patients out to non-medical services that focus on supporting them to improve their health and wellbeing (such as therapies).

Many examples of errors in transfers of care are so common in outpatient settings that they may have become normalised: 

• Patients are sometimes described as being ‘lost to follow up’, which is when they were meant to have a further appointment and it didn't happen because somewhere in the system this information has not been passed on or processed. In outpatients, we talk about it as if that's a normal thing to happen, and clinicians don't report it or recognise the risk associated. 
• We commonly see people in clinic without the results or scans we need in front of us, either because the tests have not happened or the results have been lost or not processed. It results in delays to care that can last months. Again, this is not something that is likely to appear on a Datix report.
• A variation on this is when a patient has a test or scan, and the report containing the results does not reach the requesting clinician, or their delegate, to be reviewed and acted on.
• We also commonly see and make treatment decisions in outpatients without access to patients’ primary care or other hospital records. This means we can’t see their full clinical information, including current and previous medicines. However, patients nearly always assume we can see this information in their digital hospital record.

Many errors associated with transfers of care relate to failures to pass on correct, relevant and complete information. However, we don’t have a strong evidence base about how this contributes to diagnostic errors and delays in outpatient settings. 

Triage and waiting list errors

Another area prone to error is triage, which is the initial assessment process that happens when a patient is referred for an outpatient review. As consultants providing specialist care, the NHS also now asks us to provide an advice and guidance function, which is where we decide whether a patient needs specialist review and how urgently. Safe and effective triage, advice and guidance relies on the GP giving complete and comprehensive information, current and previous test results being available and the consultant doing the triage interpreting the information provided accurately. There’s a lot of scope for key details to be missed, and we have to make a decision without seeing the patient, which increases this risk.

Triage can in theory improve safety, by ensuring people get the care they need, prioritising those with the most urgent need and allocating scarce specialist resources. It allows patients who don’t need to go onto a waiting list to have specialist advice much sooner. But when we make an error in triage and don't see someone who should have been seen, we never find that out. We aren’t tracking which decisions were correct so we have no basis to evaluate whether any patients are coming to harm. That means we’re not building any learning into the system. 

As a system, we are trying to address the risks of long waiting lists by using triage to prioritise care. Even when triage correctly identifies someone who should be seen, however, the level of urgency can be missed. Given long NHS waiting lists, this means that there are going to be people harmed because triage did not identify their need to be seen within a short timeframe. This is discussed in cancer diagnosis, but we need to look at the implications for other services.

Medication and prescribing errors 

Medication errors are common in outpatients. We often have incomplete information about what the patient is already taking which means there is an element of risk when making decisions about what you should prescribe. There is a particular risk of this at the moment, as we are often prescribing medications for patients rather than asking their GP to prescribe because the system is so overloaded. This increases the risk of missing the fact that the patient is on contraindicated drugs or that they're allergic to a medication.

There is no national system that allows healthcare professionals to see when patients are on medications that require monitoring. Having a system that alerted healthcare professionals when people are on these drugs without active intervention would hugely mitigate the risk of medication errors.

What needs to be done to bridge these knowledge gaps?

Care in outpatients is poorly coded, which means that the clinical pathway is hard to track.  We need systems that code symptoms on referral and diagnoses following specialist review, so that research bodies can invest in studies that quantify and examine the harm that happens in outpatients that currently goes untracked. At a local level, trusts could look at tracking small cohorts of patients to assess the quality of their triage systems and identify why patients are slipping through the net.

In our next blog, we will explore how empowering patients to take a more active role in their care will help reduce the risk of errors in outpatients. 

Reference

1. Levine DM, et al. The Safety of Outpatient Health Care: Review of Electronic Health Records. Annals of Internal Medicine, 2024; 177: 6. https://doi.org/10.7326/M23-20.

Further blogs in the outpatient series:

• Patient safety in outpatients: What are the risks and why aren’t we dealing with them?
• Patient safety in outpatients: Supporting patients to help keep themselves safe

Get involved

If you work in outpatients, or are a patient with experience of outpatients and ideas about how to improve safety, we’d love you to join the conversation. You can:

• comment on this blog (you will need to sign up for free to join the hub first).
• share your experience as a patient, relative, carer or member of staff in our community conversation.