The safety of our patients is an important aspect of healthcare and is the basis of quality healthcare. When patients come to the healthcare system there is an expectation of safety and quality healthcare however this is often not realized due to errors caused by healthcare workers. Reducing these errors will lead to improvements in quality of care and patient safety. According to Nickitas, Middaugh, and Aries (2016), the Institute of Medicine in a 1999 Seminal report stated that “To ERR is human” meaning that errors are inevitable because of the human aspect of healthcare. The Institute of Medicine’s (IOM) seminal report in 1999, To Err, is Human: Building a Safer Health System became the basis of policy actions to improve patient safety. The goal of this report was to design healthcare processes to ensure processes of care that will protect patients from accidental injury. According to Rodziewicz, Houseman, and Hipskind (2021), approximately 400,000 hospitalized patients experience some type of preventable harm each year resulting in approximately 100,000 people dying each year and a c to hospitals of which costs approximately $20 billion per year. The IOM report (1999) gave rise to federal agency initiatives to improve patient safety in healthcare. One such agency is the Agency for Healthcare Research and Quality (AHRQ). The AHRQ is a federal agency tasked with improving the safety and quality of America’s health care system by developing the knowledge, tools, and data needed to improve the health care system (AHRQ, 2021). After the 1999 IOM report, AHRQ has been extremely effective in addressing patient safety. According to AHRQ, the U.S. health care system prevented 1.3 million errors, saved 50,000 lives, and avoided $12 billion in wasteful spending from 2010–2013 (AHRQ, 2021). Some of the more popular tools developed by AHRQ are the Team Strategies and Tools to Enhance Performance and Patient Safety 2.0 (TeamSTEPPS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), Guide to Patient and Family Engagement in Hospital Quality and Safety, Surveys on Patient Safety Culture (SOPS) (AHRQ, 2021).

2. The majority of health care errors occur in inpatient settings. Errors are becoming increasingly common in outpatient settings. Discuss at least two (2) reasons for the increasing errors in outpatient settings.

Medical errors are a serious public health problem and a leading cause of death in the United States. There are two main categories of errors; Errors of omission occur as a result of actions not taken and Errors of the commission occur as a result of the wrong action taken (Rodziewicz, Houseman, & Hipskind, 2021). Medication errors are classified as errors of commission which are a big problem in the hospital setting as well as in ambulatory care. In a 2011 study by Sarkar et al., more than 4.5 million ambulatory care visits occur every year due to adverse drug events. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices. Risk factors for ADE include polypharmacy as well as health literacy. In ambulatory settings, polypharmacy is a big problem and medication reconciliation by healthcare professionals is one way to reduce the dire effects of polypharmacy. The level of health literacy of patients and their caregivers is a source of ambulatory care medical errors. This leads to patients not taking the medication as prescribed which can lead to detrimental outcomes. Another major error in ambulatory settings is missed diagnostics. In a 2014 study, The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations, by ​​Singh, Meyer, and Thomas, it is estimated that 5% of adults in the United States experience a missed or delayed diagnosis each year. Missed diagnosis can delay treatments and reduce the likelihood of a good prognosis.

Reference

Rodziewicz, L., Houseman, B., and Hipskind, E. (2021). Medical Error Reduction and Prevention. https://www.ncbi.nlm.nih.gov/books/NBK499956/

Sarkar, U., López, A., Maselli, H., Gonzales, R. (2011). Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. https://pubmed.ncbi.nlm.nih.gov/21554271/

Singh, H., Meyer, N., Thomas, J. (2014). The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. https://pubmed.ncbi.nlm.nih.gov/24742777/

The Agency for Healthcare Research and Quality. (2021). Agency for Healthcare Research and Quality: A Profile. https://www.ahrq.gov/cpi/about/profile/index.html

The Agency for Healthcare Research and Quality. (2019). Ambulatory Care Safety.

https://psnet.ahrq.gov/primer/ambulatory-care-safety

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