Patient safety in outpatients: What are the risks and why aren’t we dealing with them?

Summary

In 2022-23 there were nearly 125 million outpatient appointments in NHS hospitals in England, resulting in over 95 million outpatient attendances.[1] In spite of this, the healthcare system has historically paid less attention to reporting, tracking and improving patient safety in outpatient settings than it does in other areas of healthcare, such as inpatient departments and maternity services.

In this blog, NHS rheumatology consultants Anne Kinderlerer and Benjamin Ellis highlight some of the key patient safety risks in outpatients and outline why these issues have been neglected by health systems. They introduce five major patient safety issues, which will be discussed in a series of subsequent blogs.

Content

Harm happens every day in outpatient settings. Although the immediate risk of serious harm to an individual is less than in many inpatient settings, the volume of patients seen is much larger—and that means the overall level of harm across outpatients is high.

Outpatient errors are typically situations where something has been missed, rather than something having been done to a patient, like a medication error. We see the same errors happening every day in outpatients: investigations that haven’t been scheduled, patients being ‘lost to follow up’ and scan results that haven’t been reported. There is often a delay between the error happening and the harm that it causes which makes recognition and  reporting of errors harder and limits learning. One of the areas of highest risk is in transfers of care, which we refer to as ‘handoffs’. Each patient is likely to need multiple handoffs in outpatient care, and unlike inpatient care the patient is not physically present while these are awaited. So this requires particularly strong systems and communications to prevent errors. For example, if a referral to another specialty is missed, this will cause a treatment delay, during which time the patient’s condition might get worse. 

There are a number of other significant patient safety risks associated with outpatients. Patients may deteriorate while on long waiting lists and there is no simple system that allows patients or GPs to flag this to the specialist team. Tests, results and parallel appointments may not happen quickly enough or in the right order. There is a risk that patients will miss out on treatment because communication between primary and secondary care teams doesn’t allow for the correct decision about triage to be made. This is a particular issue when both services are under pressure to reduce the number of patients seen.

Although these errors often cause harm—and at the very least inconvenience to the patient—they are rarely reported and are often just seen as ‘something that happens’. There are a few reasons for this. Because the harm is less obvious, it is harder to track and that’s reflected in the lack of reporting of errors via systems like Datix. There is also a perception that outpatient errors are less serious than those that happen in inpatients. The lack of data and evidence for harm in outpatients limits our ability to change our systems to prevent the same errors happening again and we think this needs to change. We want to highlight five important aspects of patient safety in outpatients:

1. Gaps in measuring and reporting harm in outpatients.
2. Empowering patients to help keep themselves safe.
3. (Re-)engineering outpatients for safety.
4. Transfers of care and creating a collaborative culture.
5. Using digital tools to enhance patient safety.

With more research, funding and attention, we believe it is possible to decrease the number of errors and improve patient safety and quality of care for the millions of people who access NHS outpatient services every year.

Reference

1. NHS England. Hospital Outpatient Activity 2022-23, 21 September 2023

Further blogs in the outpatient series:

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