Strategies to tackle outpatient errors
From the June ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
PHILADELPHIA—A chest X-ray shows a suspicious lesion, but it gets filed in the patient's record without any follow-up. At the patient's next visit, you see the X-ray, notice the lesion, order a workup and find out the patient is fine. Have you made an error?
Some physicians would say no, because the patient suffered no harm. But Craig R. Keenan, ACP-ASIM Member, primary care residency program director and assistant clinical professor at University of California, Davis, would strongly disagree.
"Yes, it's a huge error, because you're letting test results slip through the cracks in your practice," said Dr. Keenan, one of three physicians who gave an Annual Session presentation on preventing outpatient errors. "Even if you were fortunate with that one patient, your current system could be delaying needed care."
Dr. Keenan notes that near misses are a warning that your practice systems need to be overhauled.
Such near misses are a clear warning, Dr. Keenan pointed out, that your practice systems could be a hazard to patients. Many outpatient errors are preventable, he said-and are often heralded by repeated near misses that physicians can't afford to ignore.
While much of the discussion about patient safety has focused on medical errors in hospitals, much less has been written about errors in the outpatient setting. But that's where many physicians need all the help they can get.
"Most of us in primary care don't have the computer-based safeguards that many hospital physicians do," said panelist Kwabena O.M. Adubofour, FACP, medical director of Fifth Street Medical Center in Stockton, Calif. "We need concrete approaches to reducing errors because we can't rely on anyone else."
Panelists noted that in the last two decades, outpatient practices have seen their patient load—and the potential for mistakes—rise dramatically. Dr. Adubofour pointed out that between 1983 and 1999, the number of outpatient visits jumped 75%, while inpatient days fell by more than 20%.
Today's office-based physicians run a particular risk of medication errors, which are now the second leading cause of malpractice claims. (Failure to diagnose claims are still more frequent.) The number of drugs on the market has jumped 500% in the past decade, Dr. Adubofour said, while 75% of all primary care office visits are associated with initiating or continuing some form of drug therapy.
While some errors may be just bad mistakes, most can be traced to bad management decisions and poorly designed systems. Dr. Adubofour and his colleagues outlined the major types of errors that occur in office-based settings and offered tips to help you avoid them in your practice.
Abnormal test results. If your practice doesn't routinely follow up on abnormal labs, X-rays and other test results, you're making a potentially deadly mistake. Implement a system that tracks the date you ordered a test, when you received the results and the date you notified the patient.
While your system may be as simple as keeping a test logbook, Dr. Keenan suggested that you put one staff member in charge of your tracking system, and adopt a practice-wide policy that no test results get filed in charts until you sign off on them. He also said that you should notify all patients of test results.
"The old standby mindset of 'if it's normal, I won't call you' is dangerous," he said. "It can let suspicious results slip by."
Adverse drug reactions. Dr. Adubofour pointed out that many recently approved drugs have been tested on only 2,500 to 5,000 patients in initial clinical trials. As a result, he said, it's essential to track adverse events that often don't become apparent until drugs have been out on the market.
"Primary care physicians have to become more aware of the adverse drug events associated with drugs they commonly use," Dr. Adubofour said. "A medication error takes place when you continue to prescribe a drug to a patient who's manifesting an adverse drug reaction."
He quickly added, however, that physicians also need to monitor many established medications. ACE inhibitors, for example, can induce hyperkalemia in some patients, an event you need to track. And if you prescribe long-term glucocorticoids—which can cause osteoporosis and a host of other complications—you may want to consider obtaining baseline DEXA scan data. You may also need to monitor for diabetes mellitus and hypertension with long-term glucocorticoid use.
"It's an error to not inform patients ahead of time about potential side effects from chronic use of certain medications," he explained. "It's also an error to continue to prescribe the drug without monitoring for those adverse effects."
Any drug that requires monitoring poses a high risk of error, including anti-seizure medications, digoxin, insulin, oral hypoglycemic agents, thiazolidinediones and warfarin. And, Dr. Adubofour pointed out, "if you're going to prescribe a drug that's been on the market for two years or less, make sure you watch that patient more closely for any adverse events."
In order to reduce their malpractice risk, some physicians are even beginning to draw up contracts with patients who take drugs for chronic conditions. They then have on record patients' acknowledgment that they've been informed about the potential risks of long-term drug use.
Dr. Keenan recommended setting up a tracking system that tells you when patients need to be seen and tested. He keeps a monthly calendar on his desk, with daily notations of when patients are supposed to get their lab work done.
"We check it every morning," he said. "If two days go by and we haven't seen that patient's results, we get on the phone. It takes a lot of vigilance, but it works."
Another simple safeguard: Don't issue automatic refills of medications that require monitoring, but give patients refills only after they've been tested. And make time to read package inserts and medication warnings, Dr. Adubofour said. Studies have shown that less than 15% of physicians comply with FDA warning letters that recommended testing liver enzymes in patients being treated with troglitazone (Rezulin).
No-shows. Put a system in place to contact no-shows, and take the time to look through all missed- or canceled-appointment charts to see if urgent rescheduling is required.
"A skin biopsy result showing melanoma can't wait three months, but it can easily be lost in the shuffle when the patient misses or cancels an appointment," Dr. Keenan said. Document all contacts—or attempted ones—with the patient, and make every reasonable effort to follow up.
"Even if it's the patient who's in error, the burden is on the physician—and that's not just one phone call," he added. "In my practice, I've sent patients certified letters many times."
Referrals. Set up another tracking system to note the date of a referral appointment, if the patient went and when you received the consultant's report. While you should track all referrals, flag those that are urgent or crucial.
Also be sure to talk to consultants. Errors often occur during shifts between inpatient and outpatient settings, or when care is divided between primary care physicians and specialists. Dr. Adubofour recalled one cardiologist who assumed a referred congestive heart failure patient hadn't received diuretics or potassium supplements. As a result, he prescribed the same medications the patient was already taking under Dr. Adubofour's direction, and unknowingly doubled the patient's doses.
"By the time I saw her," he said, "she was as dry as a bone." When you see patients after a referral, review with them any medications the specialist prescribed.
Also be sure to establish communication protocols with covering physicians and hospitalists. You should talk to hospitalists when patients are admitted and discharged, and set up before-and-after communications with covering physicians as well.
Failure to diagnose. This error is particularly prevalent in cancer patients, although failure-to-diagnose errors also occur with fractures, myocardial infarctions and infections.
Frequently, diagnosis failures are related to other errors of omission, like letting abnormal test results be filed without follow-up. But they can also result from false assumptions.
"We often trivialize a patient's concerns about a breast mass, particularly if she's younger, or we assume that rectal bleeding must be hemorrhoids," said Ashok V. Daftary, FACP, assistant medical director of Sutter-Gould Medical Group in Stockton, Calif.
Instead, suspect cancer first, and rely on objective evidence instead of assumptions, he said. Follow up on complaints even when tests are negative. Mammograms, for example, can come back negative even when lesions are present, Dr. Daftary said.
Vaccines and maintenance procedures. If you fail to keep on top of screening and other maintenance procedures, you may be inducing an error by jeopardizing patients' health and failing to make a timely diagnosis.
Some studies indicate, Dr. Daftary said, that less than 5% of eligible patients are immunized against pneumonia, less than 30% receive annual breast cancer screenings, less than 13% get annual fecal occult blood test screenings and less than 34% have their lipids checked.
Dr. Keenan recommended establishing a reminder system to monitor patients' health care maintenance. Computerized reminders can be helpful, he said, or you can keep a summary sheet for easy access at the front of patients' charts to check during each visit.
"A big problem is that we run out of time and can't address all those needs in the last 20 seconds of the visit," said Dr. Keenan. "But talk about at least one procedure every time the patient comes in."
Patient education. Patients and their families can be your strongest allies in the fight against errors, panelists said. If they understand what procedures or tests need to be done or what medications they should take, they often pick up errors or omissions. Discuss all therapeutic and medication options with them, and document informed consent.
When it comes to errors, medication mistakes are a hot spot for all physicians, but particularly for internists and other generalists. Drug errors are the second-leading cause of malpractice litigation, and internists and family physicians are involved in nearly half of all medication error claims.
One obvious way to reduce prescribing errors is to issue scripts using an electronic medical record or handheld computer. Studies have found that electronic prescribing reduces inpatient medication errors by 55%, said Craig R. Keenan, MD, assistant clinical professor of medicine at University of California, Davis.
Because e-prescribing has yet to catch on with most physicians, however, handwritten prescriptions are still a fact of life. Dr. Keenan offered the following tips to make your prescriptions as safe as possible:
- Use printing, not cursive, and write legibly.
- Note the purpose of the drug, such as "for high blood pressure," on each prescription. Notations help educate patients and allow pharmacists to catch mistakes.
- Always use metric weights, not grains. They are too easy to confuse with grams.
- Write out "units" instead of using "U." That abbreviation is often mistaken for a zero—and can lead to massive overdoses.
- Put a leading zero before the decimal point if the amount being prescribed is less than one ("0.5"). This helps pharmacists recognize the decimal point. Never use a trailing zero after the decimal point ("5.0"). The decimal point is too easy to miss and can result in an overdose.
- Use English directions, not Latin. (Specify "daily" instead of "qd.")
- Give specific directions for use instead of "use as directed," and specify the number of refills.
If you or a nurse calls in a prescription, always spell the name of the drug and avoid abbreviations. Say each numeral of dosage amounts, such as "five-zero milligrams" for 50 mg, and have the pharmacist read back the entire prescription. Be sure to document the prescription in the patient's chart.
Keep an up-to-date medication and allergy list for patients in their chart, and be sure to ask patients about any over-the-counter or herbal medications. If patients can't remember the names of all their medicines, have them do "brown-bag rounds" and bring in every vial or bottle of medication they use.
Pay particular attention to prescriptions when patients are discharged from the hospital. Chances are they're bringing home new medications that you should check against drugs they're already taking. Give patients written instructions at discharge about medications, and have your office contact their outpatient pharmacy after discharge to notify them of any medication changes.
Avoid what Dr. Keenan called "the prescription cascade" and make sure that new symptoms aren't a side effect of a drug patients are already taking. And let patients know why they're being given a drug, what it is and how often they should take it. That helps them be more vigilant against errors that can occur at the pharmacy.
Finally, be particularly cautious when prescribing medications for elderly patients. "Their lower body fat and slower metabolism and elimination means they may need lower doses," Dr. Keenan said. "Start low and go slow."
The College offers online tips and information on patient safety initiatives. Resources include a weekly safety tip and pointers to help reduce medical errors. For more information, see www.acponline.org/ptsafety/index.html.
Point-of-care resources can help with diagnosis and management. They also help physicians avoid relying so heavily on memory, which experts say is key to preventing all kinds of errors. The College recently debuted its Physicians' Information and Education Resource (PIER), an electronic point-of-care service that is free to College members. Go to http://pier.acponline.org and use your College ID number for access.
The FDA's MedWatch Safety Information and Adverse Event Reporting Program lets you report adverse medication events and get up-to-date information about medication safety concerns. You can also sign up for automatic e-mail alerts. Go to www.fda.gov/medwatch/ or call 800-332-1088.
The Institute for Safe Medication Practices sends out biweekly alerts via fax or e-mail on medication and device errors. For more information, see www.ismp.org/Pages/Newsletter.htm.
The Massachusetts Coalition for the Prevention of Medical Errors publishes a handbook for patients, "Your Role in Safe Medication Use." It can be found online at www.mhalink.org/publications/docs/consumerguide.pdf.
This year, the California Academy of Family Physicians published a monograph on outpatient errors called "Diagnosing and Treating Medical Errors in Family Practice." It is available online at www.familydocs.org/PDFs/MonographMedErrors.pdf or can be ordered for free by calling 415-345-8667.
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