Performance Improvement 2013-2014. What Infrastructure, Tools and Data Are Needed to Measure Ambulatory Care Patient Safety Events?

01/01/2014

Since the Institute of Medicine published its landmark study “To Err is Human” in 2000 estimating that up to 98,000 deaths in hospitals result from medical errors, much attention has been paid to medical errors in the hospital setting. Despite a shift towards increasing delivery of care in the outpatient setting, comparatively little is known about the occurrence of medical errors in ambulatory care settings.

This study assessed current literature on ambulatory patient safety events, and found that, while there were many activities occurring in the outpatient setting to address safety, systematic reporting and evaluation of ambulatory events occurring across the entire spectrum of ambulatory care at a national level was needed. The project explored policy levers to enhance the healthcare system's ability to accurately and reliably measure and track these events. Levers identified included:  prioritizing specific areas within ambulatory care to focus on initially, standardizing definitions and taxonomies, exploring electronic health records as an important data source, and extending the culture of safety from inpatient to ambulatory settings.

Report Title: Infrastructure, Tools and Data Needed to Measure Ambulatory Care Patient Safety Events
Agency Sponsor: OASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Pierre Yong, 202-690-8384
Performer: The Lewin Group
Record ID: 9741 (October 1, 2012)

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