Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies

Despite 1.2 billion ambulatory visits in 2005, from a health care quality and safety perspective, the ambulatory setting has been less subject to research and scrutiny, compared to high-risk inpatient areas like surgery, perioperative and perinatal care, and the emergency department (ED). The ambulatory environment is prone to problems and errors that include missed/delayed diagnoses, delay of proper treatment or preventive services, medication errors/adverse drug events, and ineffective communication and information flow. Once there is clarity about the nature of outpatient errors, evidence-based teamwork tools, strategies, behaviors, and principles can be implemented as countermeasures to elements of the error chain. From the resources of the TeamSTEPPSTM initiative, six effective and evidence-based tools and strategies are offered for use by clinicians in the ambulatory setting to improve the quality and safety of patient care by improving teamwork and communication. Introduction: Realities and Harm in the Ambulatory Care Setting Patients and health care providers have become increasingly aware of medical error and system problems causing poor outcomes in high-risk inpatient environments, including surgery, perinatal care, intensive care, and the emergency department (ED). In contrast, care provided in the ambulatory setting has received less scrutiny and is often perceived as safe and routine, focusing on relatively healthy patients. The volume of care within the United States for outpatient services is estimated at 1.2 billion visits to physician offices, clinics, and emergency rooms in 2005, a rate of four visits per person annually. Trends indicate increasing numbers of outpatient visits for primary and specialty care over the past decade, with similar trends in ambulatory procedures, which numbered 31.5 million in 1996. Compared to inpatient hospital care, the outpatient environment often is dispersed geographically and lacks infrastructure support. For patients, this potentially creates problems with continuity of care and confusion.