There has been a huge shift from delivering the majority of medical care in acute care hospitals to a variety of ambulatory care and community-based settings.

Ambulatory care describes the services provided in settings where the patient does not stay overnight.

Ambulatory care is provided in clinics, urgent care centers, ambulatory care surgicenters, substance abuse centers, imaging centers, physical therapy centers, physician, and nurse practitioner run offices, dialysis centers and many other specialized centers. More than three-quarters of all operations in the United States are now performed in non-hospital settings. There are thirty times more outpatient visits than hospital discharges annually.

Patient Safety in Ambulatory Care

When it comes to risk management and patient safety issues, outpatient care is very different from hospital settings. Risk management and patient safety are well established in many hospitals. Many have risk managers, compliance officers, and quality improvement staff, but most ambulatory settings lack this framework.

Ambulatory care provides care to many high-risk patients with complex needs. The system has many opportunities for errors to occur. Consider what happened to this Tennessee woman as a result of misfiling a letter.

In Roben Carter and Timothy Carter v. U.S.A, in June 2008, a woman from Tennessee went to a clinic as part of a hospital when she had a lump in each of her breasts. The nurse practitioner ordered a mammogram and ultrasound, which were done in July 2008.

The radiologist reported not seeing a solid or cystic mass in the right breast and saw multiple benign-appearing lesions in the left breast.

The Chief of Mammography Services wrote a letter recommended the patient see her primary care provider for a referral to a surgeon because there was a palpable lump. The letter was placed in her mammography file and not her treatment file; the patient did not receive this letter.

In November 2008, the patient saw another nurse practitioner; a second mammogram and ultrasound was ordered and then canceled. The patient had an ultrasound done on the left breast in January 2009; it was interpreted as benign.

The patient returned to the clinic in March 2010. An image of the right breast leads to a needle biopsy which showed cancer. The patient was diagnosed with stage 3 cancer and underwent surgery and chemotherapy. She claimed there was a delay in diagnosis of her cancer and that her prognosis would have been better if her cancer was diagnosed earlier.

Her attorney was able to show through expert evaluation of the electronic medical records that the mammogram and ultrasound reports had been signed off on by a nurse practitioner at the clinic.

The jury awarded $5.2 million dollars in this case reported in June 2014.

Communication Errors in Ambulatory Care

The Joint Commission, which accredits many inpatient and outpatient facilities has identified that miscommunication is one of the most common reasons for medical errors. Communication errors may occur between healthcare providers and patients who are functionally illiterate and between doctors and nurses or medical assistants, or other healthcare personnel.

Communication Errors Among Staff

Communication errors may occur which result in incorrect diagnoses, incorrect instructions to patients, or lack of continuity of care when the patient moves from an ambulatory care setting to the hospital or back to ambulatory care.

Communication errors are improved with some specific communication techniques. Attorneys will see references to some of these techniques when they read medical records. (These techniques are not limited to ambulatory care.) These include:

• Structured handoffs – following a format for giving each other patient information using standardized processes for information handlings, such as a checklist or form
• Read back of telephone orders – writing down the order and then reading it back to the provider to ensure understanding
• Verification of verbal orders – repeating back what the provider has ordered
• Briefing – a gathering that involves bringing healthcare team members together to share important information, ask for input, or create a plan
• Debriefing – a team activity that provides the opportunity to review an event to evaluate how the term performed
• Huddle – a quick meeting in response to changing circumstances that require problem-solving, such as when the office schedule is thrown off by an emergency
• Two challenge rule – a person who receives a message and has a concern about the safety of the message, states twice, if necessary, the concern. The person providing the message is obligated to acknowledge the concern.
• Electronic medical records – interdisciplinary providers may access the patient’s records, test results, and plan of care and easily locate information within the record.

Communication is a huge and complex issue within health care. Misunderstandings may have deadly results.

Med League provides medical expert witnesses to trial lawyers. Please call us at (908)788-8227 or contact us today to discuss your next case.