Editor’s Notebook

November / December 2010

Editor’s Notebook

Ambulatory Practices Join the Conversation

Ambulatory practices find themselves in the patient safety spotlight with increasing frequency, for a number of reasons: more attention is being paid to diagnostic errors, which often trace back to physician practices; with implementation of electronic health records, more data will be available and analyzed for medical care delivered in ambulatory settings; and as improvement efforts in hospitals mature, it simply is time to bring more of healthcare into the safety conversation. Recently, I’ve seen evidence that it truly will be a conversation; a two-way conversation. Private-practice clinicians and staff members in ambulatory settings will receive more scrutiny, but they—and their patients— will bring new perspectives and make important contributions to established safety practices.

I saw such a contribution made recently, at a screening of Healing the Healers, a documentary film by CRICO/RMF. The screening, sponsored by the Massachusetts Medical Society in collaboration with CRICO/RMF and the Kenneth B. Schwartz Center at the annual Schwartz Center Speaker Series program, attracted a thoughtful, multidisciplinary group of healthcare professionals from the Boston area. A lengthy Q&A session followed a screening of the 19-minute film, in which clinicians describe from personal experience what it feels like to face the reality of having made a mistake and harmed a patient, without empathy, understanding, or support from their peers or employer. During the Q&A, a number of primary care physicians said they often feel overlooked and want to be contacted if one of their patients suffers harm outside of their practice so they can assist the patient, families, and clinicians involved with whatever response is necessary and to offer support. It was inspiring to witness; the primary care docs offered feedback and assistance—across a significant divide—to their hospital colleagues, who seemed to hear and appreciate the offer. If communication improves across the divide, primary care clinicians will find that they shoulder additional scrutiny and responsibility for the care they deliver; I hope they will also gain resources and collegiality in the exchange.

Another example of expanded conversation comes from the National Patient Safety Foundation’s listserv. Jim Conway, senior fellow at the Institute for Healthcare Improvement (IHI), posted a link on the listserv to Respectful Management of Serious Clinical Adverse Events, an IHI report that applies primarily to hospitals. Kerry O’Connell, a knowledgeable patient safety advocate, responded, questioning the report’s focus on “high-profile sentinel events.” In his message, O’Connell says, “40% of harm occurs from missed diagnoses where patients learn far too late their true condition. Here there is no crisis event to manage. Patients suffer and eventually die with no one other than the doctor ever knowing why.” O’Connell’s message is chilling and another reminder that if we focus safety attention solely on hospitals and high-profile events, there is much that we will miss.

Obvious problems beg for attention; they are hard to ignore and offer a clear target (even if the solutions have been elusive and slow). In the case of harm done in ambulatory settings, it will take additional observational skills, technology—and fortitude—to discover and address the problems. It’s good to see the patient safety community and conversation expanding.