Electronic Clinical Surveillance to Measure and Improve Safety in Ambulatory Care

 描述(由申请人提供)：尽管美国每年估计有10亿人次的门诊就诊，但改善患者安全的努力主要集中在住院设置上。在这里，我们建议研究三种类型的医疗差错的发生率，以及在大型、多样化的综合递送系统的门诊护理环境中导致这些差错的潜在因素。具体地说，我们将研究：诊断错误(肾脏疾病的延迟诊断)、治疗错误(有跌倒病史的患者使用禁忌药物)和预防错误(对血管紧张素转换酶(ACE)抑制剂或血管紧张素受体阻滞剂(ARB)的患者缺乏年度监测)。在非卧床护理环境中识别和干预护理差距存在独特的挑战。护理通常是分散的，涉及多个提供者很长一段时间。在某些关键信息(例如实验室结果)的提供方面存在固有的延迟。此外，一些护理差距只有在其原因几周或几个月后才能被发现(例如，未能跟踪异常测试结果只有在正常的后续时间过去后才明显)。此外，更多的健康患者出现与有严重健康状况的患者相似的症状，这可能导致漏诊或延迟后续护理。而且，在门诊环境中，患者在护理质量方面发挥着更大的作用。尽管电子健康记录被发现不足以解决护理差距本身，但它们为研究门诊环境中的医疗差错提供了一种有效的方法。在综合交付系统中尤其如此，在这种系统中，跨越不同环境和长时间的护理过程得到了全面的记录并容易地联系在一起。我们建议确定2010-2015年间南加州凯撒永久医院(KPSC)内三种医疗差错的发生率(目标1)和风险因素(目标2)。KPSC为400万现有会员的多样化人口提供服务，估计每年有1200万次门诊就诊，提供服务的提供者超过6000人。我们将利用KPSC先进的电子健康记录和门诊安全创新计划，有效地识别高危患者队列，并使用泊松回归估计MEDICA错误的发生率和风险因素。我们还将通过对患者和提供者的一对一访谈(n=90)和外部咨询委员会的意见(n=5)，深入了解门诊护理中医疗差错的原因和潜在的干预措施(目标3)。这项研究将产生关于门诊护理环境中三种类型医疗差错的发生率和风险因素的新信息。我们的长期目标是通过使用电子健康数据为有意义的患者护理改进做出贡献。这项研究是迈向这一目标的第一步，因为它将产生信息，为未来的研究和干预提供信息，以提高门诊护理的安全性。

 DESCRIPTION (provided by applicant): Efforts to improve patient safety have largely focused on inpatient settings, despite the fact that there are an estimated one billion outpatient visits each year in the United States. We propose here to study the incidence of three types of medical errors and the underlying factors that contribute to them within the ambulatory care settings of a large, diverse integrated delivery system. Specifically, we will study: diagnostic error (delayed diagnosis of kidney disease), treatment error (the use of contraindicated medications among patients with a history of falls), and preventive error (lack of annual monitoring for patients on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)). There are unique challenges to identifying and intervening on care gaps in ambulatory care settings. Care is often diffuse, involving multiple providers over long time periods. There is an inherent delay in the availability of certain key pieces of information (e.g., laboratory results). Additionally, some care gaps only become identifiable weeks or months after their causes (e.g., failure to follow-up an abnormal test result is apparent only afte the usual time for follow-up has elapsed). Further, a greater number of healthy patients present with similar symptoms as patients who have serious health conditions, which may contribute to missed diagnoses or delayed follow-up care. And, patients play a greater role in care quality within ambulatory settings. Although electronic health records have been found to be insufficient for addressing care gaps themselves, they offer an efficient way to study medical errors in ambulatory settings. This is particularly true within integrated delivery systems, where processes of care across different settings and long time periods are comprehensively documented and readily linked. We propose to determine the incidence (Aim 1) and risk factors (Aim 2) for 3 types of medical errors within Kaiser Permanente Southern California (KPSC) from 2010-2015. KPSC serves a diverse population of 4 million current members, seen by over 6,000 providers in an estimated 12 million annual outpatient encounters. We will leverage KPSC's advanced electronic health record and innovative program in outpatient safety to efficiently identify cohorts of at-risk patients and to estimate the incidence of, and risk factors for, medica errors using Poisson regression. We also will generate insights into the causes of, and potential interventions for, medical errors in ambulatory care (Aim 3) through one-on-one interviews of patients and providers (n=90) and via input from an external Advisory Board (n=5). This study will generate novel information on the incidence and risk factors for 3 types of medical errors in ambulatory care settings. Our long-term goal is to contribute to meaningful patient care improvements through the use of electronic health data. This study represents a first step toward that goal, as it will generate information to inform future research and interventions to improve ambulatory care safety.