INCREASING MEDICAL ERRORS IN THE OUTPATIENT SETTING; ARE THEY AVOIDABLE?

A recent study in JAMA (http://bit.ly/mp7zEv) showing a shift in malpractice lawsuits to the outpatient setting is not surprising. Throughout the last decade, payers have refused to pay for inpatient care when they deemed procedures to be able to be performed on an outpatient basis. Moreover, as the article speculates, the burden falling on primary care physicians (Internists, Family Physicians, etc.) has increased exponentially while reimbursements have declined and the completely un-reimbursed, purely bureaucratic burden has fallen almost entirely on them. While the concept of the Primary Care Physician ("PCP") being responsible for oversight and coordination of care, the ultimate expression of which is the "Medical Home" concept is a good one, the unfunded overload of these physicians has followed the law of unintended (but in this case, foreseeable) consequences.

Imagine coming onto the office in the morning and finding a waiting room full of patients, a list of telephone calls to be returned from patients, hospitals, pharmacies and nursing homes, a stack of laboratory reports more than eight inches high that need to be reviewed and another stack of equal size of insurance and other forms to be filled out. Moreover, unlike their increasingly technologically assisted colleagues in the hospital, they have not been able to afford the electronic systems that could eliminate many of the errors that have been eliminated in the hospital setting. At the end of the day, nearly half their time has been spent on non-clinical work while trying to see the increasing number of patients they are required to see and, when they look at their desks, the piles of reports and forms have regrown to even higher levels.

Add to this the necessity of turning over more and more care to mid-level providers for whom the physicians are responsible, because the reimbursement does not allow for adding physicians to a practice, and turning many of the screening procedures over to even lesser trained assistants, and the outcome is eminently predictable.

If I were going to design a system in which potentially disastrous errors would become inevitable, this would be such a system. Now, add to this the problem of communication failures between Hospitalists and PCPs. Patients who used to be cared for in the hospital by their PCPs, which ensured continuity of care, are now being seen by other physicians who are "less expensive." The patients, however, show up in the office before the discharge summaries arrive, leaving the PCPs with little information with which to adequately treat the patient and the recipe for disaster is complete.

The real question is not why so many outpatient errors occur, but why there are so few!