What can go wrong in the office? Isn’t patient safety something that hospitals, and to a lesser extent, nursing homes should be worrying about? How is patient safety different in the office setting as compared to the hospital?

There are two primary differences between the office practice and the hospital setting. First, many of the interventions initiated during a clinical visit have their adverse effects that are unobserved to the clinician. For instance, you prescribe a new medication to a patient who most likely will have it filled by an outside pharmacy, and begin taking it at home along with the other medications that the prescribing physician may or may not know that the patient may be taking. The prescribing physician is unaware of the medication’s effect, both beneficial and adverse, unless the patient calls you or returns to your clinic to see you or your partner. Hence, even with the best of follow up, a potential adverse effect of your prescription may not be seen by you at all. You count upon your colleagues to recognize and manage a medication adverse effect that was initiated by your prescribing.

A second difference is the sheer volume of patients that you see on a daily basis. If you order a laboratory study, for instance, on a patient in the hospital, you will receive the result back into the chart most likely within that patients hospital stay, and you will have multiple eyes looking at them, including other referral colleagues, nurses, therapists, and even family members. You may be in a hospital that has a critical value alert for abnormalities in specific testing so you may be receiving telephone calls, pages, and face to face inquiries on this test result.

For every eight people admitted to a hospital, 217 visit an office-based physician’s practice. This is 25 times more patients, laboratory studies, medication prescriptions and so forth are being generated in your office. This creates an even greater potential for error including in how laboratory results are tracked and managed in your practice.

A third difference between office practice and hospital care is the anticipatory focus of primary care practice. Primary care physicians not only treat acute conditions or exacerbations of chronic diseases that present in their offices, they also work with patients to anticipate potential medical problems that their patients may encounter in their homes or in their communities. There are patient safety events, instance falls, that occur outside the office but can be anticipated and mitigated by guidance and/or intervention that is started in the office visit.

This is the first in a series of blogs that will be focusing on the key sources of adverse events associated with ambulatory practice. These will include:

• Adverse drug events and the role of medication reconciliation
• Adverse events related to mismanagement of laboratory test results
• Iatrogenic infection control and the role of hand washing
• Falls in the home or community and the role of fall risk assessment and risk management

Although the research in each of these areas are more paltry than the same risks in the hospital, there is still evidence and opportunity for improvement.

NEXT BLOG: adverse drug events and medication reconciliation