Improving Ambulatory Patient Safety

THE 1999 INSTITUTE OF MEDICINE REPORT TO ERR IS Human: Building a Safer Health System launched the modern patient safety movement by estimating a large number of yearly error-related deaths among hospitalized patients in the United States. But 12 years later, there are no reliable data on how many patients in the United States are injured or die each year because of errors in ambulatory settings. The number may be substantial; 52% of paid medical malpractice claims in 2009 were for events in the outpatient setting, and two-thirds of these claims involved major injury or death. More than 10 years ago, a group of experts convened by the Agency for Healthcare Research and Quality (AHRQ) reported that “medical error and injury are substantial in ambulatory care, but there has been little systematic research specifically aimed at patient safety questions in ambulatory care.” To jump-start a new research agenda, the conferees made 11 specific recommendations. Virtually none have been implemented.