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Patient Safety in the Physician Office Setting

Nancy C. Elder, MD, MSPH | May 1, 2006 
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Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg.

In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith finds an unsigned abnormal Papanicolaou test result from 18 months ago.

Although most patient safety research and innovations come from the hospital setting, most health care in the United States is provided in the outpatient setting. For every 8 people hospitalized, 217 visit a physician's office, and more than half of those visit primary care physicians.(1) Stories like the above are, unfortunately, common occurrences in physician offices around the country. When mistakes happen, quality suffers, and patients suffer emotional, financial, and physical harm.(2)

Early anecdotal stories about safety hazards in the outpatient setting have progressed to large-scale studies in practice-based research networks (PBRN) and innovative practice-based interventions.(2-5) Although still limited in scope, data from these initiatives suggest that physicians wanting to incorporate patient safety efforts in their offices should concentrate initially on two areas: prescription medications and the processing of lab, x-ray, and diagnostic tests. Improved systems for these tasks could potentially lead to fewer errors and improved safety for millions of patients.(6)

Prescription Medications

Approximately two out of every three office visits result in a prescription, and, in 2002, approximately 1.3 billion drugs were prescribed or provided at these visits.(7) Studies in Colorado family practices found that 60% of reported errors associated with harm involved prescription errors.(6) In office settings, medications include injections in the office, samples dispensed by physicians, and written prescriptions filled by pharmacies. From reports from family physicians and their staffs, it appears that practices more commonly prescribe the right drug at the wrong dose, timing, or administration than they prescribe the wrong drug (or forget to prescribe a drug).(2) There are also significant discrepancies between the drugs patients are actually taking and the drugs practices have documented that they are taking.(8) In addition, many medication errors occur between hospitalization and the return to the ambulatory setting, with as many as 42% of patients discharged from the hospital suffering a discontinuity error.(9)

Recommendations compiled from the literature to improve the medication prescription process in the office setting include the following:

  • Write understandable, legible prescriptions, and include the indication on the prescription. Although bad physician handwriting is a long-standing joke, it is also the cause of errors. Using English instead of Latin abbreviations can decrease confusions (ie, writing "four times daily" or "once daily" instead of "qid" and "qd," respectively), and writing the indication on the prescription (eg, for high blood pressure or for prevention of headaches) can help patients, pharmacists, and physicians better understand the role of medications.
  • Use sample medications with care, if at all. Pharmacists serve as an important safety check when prescribing medications, often catching interactions and allergies that physicians miss.
  • Maintain accurate and usable medication lists and reconcile medications regularly. Primary care physicians are familiar with the "brown bag check-up" for their patients (ie, asking patients to bring all the medicines in their medicine cabinet to a visit), but physicians and their staff need to confirm the medications, including herbal and over the counter, that all their patients are taking at every visit. When discrepancies are found, it is the physician's task to resolve these.
  • Empower patients to serve as safety double-checkers. Most patients can assume significant responsibility for discovering—and preventing—many medical errors from becoming harmful events. When encouraged and trained by staff and physicians to double-check their medications each time they pick up a prescription, they can become even more important partners in ensuring safe care.
  • Consider using an electronic prescribing system. An electronic prescribing system, especially when interfaced with an electronic health record (EHR), has the potential to decrease errors from illegibility and interactions. Direct electronic transmission to pharmacies has the potential to decrease errors even further, although few data currently exist to support this conjecture.

The Testing Process

According to data from the National Ambulatory Medical Care Survey, the average family physician sees approximately 100 outpatients per week and orders diagnostic tests on 39% of them.(7) Between the time a physician decides to order a test and the appropriate follow-up action is discussed with the patient, practices perform a series of decisions and actions, including ordering and implementing the tests, tracking the results, responding to and documenting the response, notifying the patient, and following up as needed.(10,11) Errors are common throughout the entire process; in error reporting studies from family medicine PBRNs, problems with processing tests accounted for 14% to 47% of all reported errors.(2,3)

The medical literature suggests that the following improvements have potential to advance safety and quality in this area:

  • Implement a formal test-tracking system. A tracking system assures that all tests ordered are returned, ideally to the physician but at least to the practice. Such a system requires that all physicians in a practice agree to standardize how they order tests and how returned results will be handled. Although a formal tracking system can be incorporated within an EHR, this is not a requirement for having a working system (and this is not necessarily a standard function of all EHRs). A system needs to be simple, have some built-in redundancies (to account for human error in entering data), and be accessible and accountable to multiple people (not just "Mary in the laboratory"). Poon and colleagues developed an electronic program called Results Manager,(12) which offers an electronic method to track results, with options for reminders, treatment algorithms, and patient follow-up (Figures).
  • Make a policy of notifying every patient of every result. "No news is good news" should be a policy relegated to history. Practices should decide on a standardized system for notifying patients of both normal and abnormal results. Mold and colleagues describe a simple "best method" from their study of 24 physicians in an Oklahoma PBRN.(10) For normal and non-urgent abnormal results, a physician note is written onto the actual laboratory result sheet and dated. The medical assistant dates, initials, and stamps the same sheet, which is then copied; the copy is mailed to the patient with a generic laboratory test explanation sheet.
  • Empower patients to serve as safety double-checks. Patients should be educated as to what tests are being ordered, their purpose, and when (and how) results will be relayed. If patients do not receive their results within a specified time, they should not assume that means "everything is OK." Rather, they should be instructed to contact the office for the results.
  • Only file signed reports, letters, dictations, and results. Whereas many offices have a policy that nothing enters a chart (electronic or paper) without being signed first, too often, unsigned or inappropriately signed reports get filed. The response to the report (normal, abnormal) also needs to be noted by the physician, and empowering all who find such a breach to take steps to fix it can help ensure the system succeeds.

Patient safety in the office setting does not need to put onerous tasks on already overburdened physicians. As the Institute of Medicine noted, in ambulatory care "patient safety is indistinguishable from the delivery of quality care."(13) The suggestions offered here have potential for physicians, and their staffs and patients, to achieve not only safer care, but also improved quality and efficiency, and that is a winning situation for everyone.

Nancy C. Elder, MD, MSPHAssociate ProfessorDepartment of Family MedicineUniversity of Cincinnati


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1. Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344:2021-2025. [go to PubMed]

2. Fernald DH, Pace WD, Harris DM, West DR, Main DS, Westfall JM. Event reporting to a primary care patient safety reporting system: a report from the ASIPS Collaborative. Ann Fam Med 2004;2:327-332. [go to PubMed]

3. Dovey SM, Meyers DS, Phillips RL Jr, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11:233-238. [go to PubMed]

4. Elder NC, Dovey SM. A classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract. 2002;51:927-932. [go to PubMed]

5. Poon E, Wang S, Gandhi TK, Bates DW, Kuperman GJ. Improving the quality of abnormal test follow-up in the ambulatory setting: implementation of an electronic results manager at Partners Healthcare. Proceedings from: National Ambulatory Primary Care Research & Education Conference on Patient Safety; September 18-19, 2003; Chicago, IL.

6. West D, Westfall JM, Araya-Guerra R, et al. Using reported primary care errors to develop and implement patient safety interventions: a report from the ASIPS Collaborative. In: Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality Publication; 2005. AHRQ Publication No. 050021.

7. Woodwell DA, Cherry DK. National Ambulatory Medical Care Survey: 2002 Summary. Advance Data from Vital and Health Statistics. Advance Data No. 346. Hyattsville, MD: National Center for Health Statistics; August 26, 2004.

8. Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med. 2000;160:2129-2134. [go to PubMed]

9. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646-651. [go to PubMed]

10. Mold JW, Cacy DS, Dalbir DK. Management of laboratory test results in family practice. An OKPRN study. Oklahoma Physicians Resource/Research Network. J Fam Pract. 2000;49:709-715. [go to PubMed]

11. Hickner JM, Fernald DH, Harris DM, Poon EG, Elder NC, Mold JW. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Patient Saf. 2005;31:81-89. [go to PubMed]

12. Poon EG, Wang SJ, Gandhi TK, Bates DW, Kuperman GJ. Design and implementation of a comprehensive outpatient results manager. J Biomed Inform. 2003;36:80-91. [go to PubMed]

13. Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press; 2004.


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Figure 1. Results Manager "Inbox" Image removed.

Figure 2. Test Results Main Page Image removed.

Figure 3. Compose Follow-up Letter Page Image removed.

Figure 4. "Tickler" Page Image removed.

(Figures courtesy of Eric G. Poon, MD, MPH, Partners HealthCare System, Inc. and Brigham & Women's Hospital, Boston, MA)

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
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