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Patient Safety in Office-Based Care Settings

Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | January 31, 2024 
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Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.


Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

The Institute of Medicine’s 2000 publication To Err Is Human summarized research on the impact of medical error in hospitals, and it is credited with energizing the patient safety movement.1,2 Possibly because the report focused on the acute-care setting of hospitals, much of the early momentum in patient safety research and application focused on hospitals. Many more people, up to 23 times more, receive medical care in office-based or outpatient settings rather than in hospitals.3 Office-based settings appear to be safer than hospital settings, but patient safety incidents do occur, and given the volume of patients receiving care in office-based settings, even rare incidents may impact many people.4 High-quality office-based care, such as primary care, is essential to improve health outcomes, to decrease mortality from chronic disease, and to promote prevention. Also, many office-based settings, such as ambulatory surgical centers, have taken on care which had previously been provisioned primarily in hospitals. But challenges in office-based care settings, such as falls, diagnostic issues, and complications related to ambulatory surgery, can reduce patient safety.

Common Safety Events in Routine Medical Office Settings

With so much care provided in office-based settings, and comparably little attention paid to understanding patient safety in this setting, the ECRI Institute published an analysis of more than 4,000 patient safety events in ambulatory care centers, community health centers, and primary care provider offices over the course of a year. That analysis attempted to make an overall account of the kinds of safety issues that arise in office-based settings. The ECRI Institute found that safety events in ambulatory care fall into four main categories: diagnostic testing errors, medication events, falls, and security or safety incidents, such as workplace violence or violence from patients or trespassers.

Some of these risks overlap with those in acute settings, and may be approached in similar ways in both acute and office-based settings, for example patient falls can occur in any patient setting. AHRQ published a primer on fall prevention summarizing evidence on fall reduction in a variety of healthcare settings. The mitigation strategy of incorporating individualized fall risk screening to identify patients most at risk for falling appears effective in either acute settings or ambulatory settings.

Diagnostic testing errors and delayed or missed diagnoses also lead to patient safety events in office-based settings. For example, communication breakdowns in primary care can lead to failure to discuss abnormal test results with patients, leading to delayed or inadequate treatment. Better patient engagement and reminders can improve diagnostic safety. A delayed or missed diagnosis is more complicated, but it is prevalent in office-based settings. A study of 4,830 cases of diagnostic error in a nationwide cohort in Sweden found that cancers were often misdiagnosed in primary care settings, especially colorectal and skin cancers. But these apparent cases of misdiagnoses may be related to challenges inherent to primary care, as a review of diagnostic safety has noted. Symptom presentation is often poorly defined with non-specific presentations in the office-based setting, and diagnosis may require a longer process than diagnosis in the acute care setting. However, building awareness of frequently misdiagnosed conditions in primary care and developing tools to improve recognition of cognitive biases that may erroneously dismiss rare diagnoses may improve diagnostic safety in office-based settings.

Compared to hospital-based settings, medication prescribing in office-based settings may be associated with greater patient safety hazards because patients may be prescribed medications from many different providers, and these providers may have separate, incompatible electronic health record systems.5 A systematic review found that in office-based care, prescribing errors are the most common type of medication error, although there is variability in the data.6 Despite their frequency, medication errors in office-based settings tended to be of “mild-to-moderate” severity, although with some potential for lethality.6 In assessing factors contributing to medication errors, knowledge lapses regarding special populations or updated treatment guidelines appear to increase error, which may indicate that there is a system-level need for more education and resources.6 Medication error has been a focus of patient safety, and interventions such as software support during prescribing and pharmacist review of medications, both with patients and prescribers, have evidence of reducing harm.5,6

Violence in healthcare settings impacts patient safety, and guidance is emerging that a culture of safety may mitigate the harm of workplace violence in healthcare. Organizational strategies like clear protocols to track violent incidents and address patient violence, including regular monitoring, along with changes to the physical environment and training may help reduce workplace violence. Like other safety improvement measures, such changes could be applied in a variety of settings. In contrast to hospital settings, which typically contain multiple security checkpoints, office-based medical care centers are often designed to be easily accessible to the community, and that access might make them more vulnerable to violence, as the ECRI Institute’s survey of patient safety in office-based settings has noted. Specific office-based medical centers, such as reproductive healthcare facilities, are often targets for violent conduct such as bombings or arsons.7 However, some forms of office-based care, such as primary care, may be positioned to prevent patient violence. Data has suggested that about 85% of violent incidents had warning signs.8 Perhaps the more longitudinal relationship that typically exists in primary care could help identify these warning signs.

Safety Hazards in Ambulatory Surgery Centers

Additional safety hazards exist for surgeries or procedures conducted in outpatient, office-based settings. In the United States, more than 25 million surgeries each year are performed in ambulatory settings, marking an overall shift of a wider range of procedures and more higher-risk patients obtaining care in ambulatory surgery centers. Responding to this shift, AHRQ funded a project to reduce surgical site infections and other complications through rapid-cycle improvement in ambulatory surgery centers. Reporting on this initiative, researchers have found that low rates of complication coupled with high attrition and low data reporting rates made it difficult to collect enough data to achieve statistical significance, which limits their findings. The study authors believe that future programs could improve data collection through more robust data collection strategies. For example, it may be necessary to reduce the data submission burden and mandate data reporting for participating organizations. Additionally, educational materials and tools were developed to address safety in ambulatory care surgeries; these resources could be implemented more widely.

Beyond infections and complications from surgeries, researchers have begun to describe deviations from optimal care in office-based surgeries from both patient and clinician perspectives. They found that such deviations were common, occurring in 70% of reviewed cases. Examples of patient-reported non-routine events in ambulatory surgery include unexpected postoperative pain, vomiting, and feeling rushed out of post-operative recovery. Clinician-reported non-routine events included case delays from machine failures and staffing issues. And while clinicians tended to rate these non-routine events as low in severity, patients reported high distress related to their perceived non-routine events. Notably, better communication between clinicians and patients may reduce patient-reported non-routine events and distress.

Communication and TeamSTEPPS

Care in office-based settings has the potential to reduce healthcare costs and improve outcomes, especially for primary care, which focuses on an individual’s overall health and is often predicated on an ongoing relationship between individual and provider. But the healthcare environment’s complexity makes communication difficult. That difficulty in communication has been found to be the root cause of about 80% of all medical errors. Breakdowns in communication between different medical providers, and across medical providers, patients, and their caregivers, all contribute to lapses in patient safety in office-based care. TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is a set of evidence-based practices and tools designed to increase the effectiveness of communication to improve patient safety, especially the culture of patient safety. TeamSTEPPS addresses safety in a variety of settings, including office-based settings, with additional resources on care handoffs and team huddles specific to office-based settings. Reporting on implementing TeamSTEPPS in office-based settings, researchers noted improved communication, decreases in clinical error rates, and better patient satisfaction.8,9 Continued implementation of communication strategies in teams, coupled with more interoperative technologies that may improve communication between healthcare teams, is likely to increase safety in office-based settings.

The patient safety movement began with dramatic findings on preventable harm in hospitals. As healthcare evolves, more patients are receiving care in office-based settings. And while some of the patient safety concerns researched in hospital settings are relevant to office-based settings, and some approaches to mitigate those harms, like communication and teamwork, apply across settings, research focused specifically on improving patient safety in office-based settings is needed. To fill this gap, AHRQ has several ongoing funding opportunities focused on Ambulatory care including Understanding and Improving Diagnostic Safety in Ambulatory Care: Incidence and Contributing Factors, Improving Diagnostic Safety in Ambulatory Care: Strategies and Interventions, AHRQ Small Research Projects to Advance the Science of Primary Care, and Making Health Care Safer in Ambulatory Care Settings and Long-term Care Facilities.

Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN
Associate Dean for Clinical Practice & Community Engagement; Exe. Director, Center for Health Policy and Media Engagement
George Washington University, School of Nursing
Ashburn, VA

Merton Lee, PharmD, PhD
American Institutes for Research (AIR)
Columbia, MD

Sarah E. Mossburg, RN, PhD
Senior Researcher
American Institutes for Research (AIR)
Arlington, VA

  1. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS, eds.). National Academies Press (US); 2000. Accessed August 3, 2023.
  2. Neuhaus C, Grawe P, Bergström J, St Pierre M. The impact of “To Err Is Human” on patient safety in anesthesiology. A bibliometric analysis of 20 years of research. Front Med (Lausanne). 2022;9:980684. doi:10.3389/fmed.2022.980684
  3. Lai AY, Yuan CT, Marsteller JA, et al. Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients. J Am Board Fam Med. 2020;33(5):754-764. doi:10.3122/jabfm.2020.05.200042
  4. Gaal S, van Laarhoven E, Wolters R, Wetzels R, Verstappen W, Wensing M. Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pract. 2010;16(3):639-643. doi:10.1111/j.1365-2753.2010.01448.x
  5. Marshall SE. Practice review: Medication reconciliation in the ambulatory setting. Nurs Manage. 2023;54(11):30-35. doi:10.1097/nmg.0000000000000070
  6. Naseralallah L, Stewart D, Price M, Paudyal V. Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review. Int J Clin Pharm. Published online September 8, 2023. doi:10.1007/s11096-023-01626-5
  7. Recent Cases on Violence Against Reproductive Health Care Providers. Published online May 30, 2023. Accessed January 1, 2024.…
  8. Deep Dive: Safe Ambulatory Care. Published online October 23, 2019. Accessed November 9, 2023.…
  9. Parker AL, Forsythe LL, Kohlmorgen IK. TeamSTEPPS® : An evidence-based approach to reduce clinical errors threatening safety in outpatient settings: An integrative review. J Healthc Risk Manag. 2019;38(4):19-31. doi:10.1002/jhrm.21352
  10. Mohsen MM, Gab Allah AR, Amer NA, Rashed AB, Shokr EA. Team Strategies and Tools to Enhance Performance and Patient Safety at primary healthcare units: Effect on patients’ outcomes. Nurs Forum. 2021;56(4):849-859. doi:10.1111/nuf.12627
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

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