Outpatient care is any care received outside the hospital. It is a far more frequent occurrence than hospital care. On average, one in four Americans receives outpatient care each month. Like the hospital setting, it is a hotbed of malpractice. Just how much, some researchers in Massachusetts decided to try and find out.
CRICO is the insurance and risk management program for all of the Harvard medical institutions and their affiliates. This includes 32 hospitals and 325 other health care organizations. CRICO is very interested in reducing the risk of patient injuries and has financed many studies into the subject of medical malpractice. A recent one studied adverse events in the outpatient setting and found that they were not much different than what we find in hospitals.
For purposes of the study, the researchers had nurses review the electronic medical records of 3103 patients who were seen at 11 outpatient facilities in the state of Massachusetts in the year 2018. The nurses flagged events that appeared to be adverse for later review by a team of physicians. An adverse event in this context is any injury caused by medical management. The physicians who reviewed the records flagged by the nursing team assessed the severity of the patient injury and whether it was preventable or not.
The patients whose records were reviewed were mostly white, English speakers with a mean age of 52 years. They had a mean 4 outpatient encounters in 2018.
Overall, 7% of the patients whose records were reviewed experienced at least one adverse event. Some experienced a number of them. Most of the adverse events resulted in injuries that were not serious, but a little over 17% of them were designated as serious and an additional 2.1% were considered life-threatening. There were no deaths among the limited number of patients whose records were reviewed. Overall, the doctors found that almost 25% of the adverse events were preventable.
The most common form of adverse event involved adverse drug events. Adverse drug events were 63% of all adverse events. The next most common was health-care associated infections at 15% and surgical procedural events at 14%. If you were between 18 and 44, your risk was significantly less than if you were older than 65. At least some of that difference probably relates to the number of medications older patients take.
Putting this in perspective, out of every ten thousand patients, 700 of them are going to experience at least one adverse event during any given year. 170 of those adverse events will have been preventable. Forty of those events will have resulted in serious injury and at least ten injuries will have been life threatening.
Now consider that there were 77,100,000 outpatient encounters in the United States in 2024. If these figures were applied to that total, that amounts to over 5,350,000 adverse events, of which over 900,000 involved serious patient injury. 229,000 of those serious patient injuries would have been preventable and many of them would have involved patient death.
The study has a number of limitations. In the first place, the study involved only a review of electronic medical records. The researchers found that when they spoke to the patients about their experiences, the patients recounted many adverse events that were never entered into the medical record. This led the researchers to conclude that the statistics they reported about the level of avoidable medical mistakes that cause serious injury or death is low and probably represents only “the tip of the iceberg.”
Because the review was limited to the electronic medical chart, it could not capture many forms of malpractice, such as delayed or missed diagnoses, which constitute a large percentage of all malpractice claims. The researchers felt they were “only grazing the surface” of the total amount of malpractice that occurs in the outpatient setting.
Lastly, the study was confined to a relatively small geographic area with somewhat narrow demographics. The statistics may and probably are much higher in poorer communities that do not offer care at the level of the Harvard institutions.
Putting all of these limitations together, things are even worse than these numbers suggest. Even with these numbers, however, the researchers concluded that outpatient harm was “relatively common and often serious.”
The people involved in this study are not radical, bomb-throwing trial lawyers looking to prove the existence of medical malpractice. They are serious medical professionals looking to improve the level of care provided in the outpatient setting. They consider their report to be a call to arms to the medical profession to improve itself. They do not believe there is any reason the medical profession cannot fashion a system that delivers care with the same degree of safety as the airline industry. We will see what happens but I, for one, am not holding my breath.
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