Patientensicherheit in der ambulanten Versorgung – Assoziation der ärztlichen Fachgruppe mit dem Auftreten und den Charakteristika von patientensicherheitsrelevanten Ereignissen
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Background: To date patient safety research has predominantly focused on the inpatient sector, with limited data available for the outpatient sector. According to the WHO, however approximately half of all patient harm occurs in outpatient care. The Patient Safety in Ambulatory Care study provides for the first time representative data on patient safety incidents (short incidents) in the German outpatient sector. The present study examines the association between medical group and specialization and the frequency of patient-reported incidents, considering both 12-month and lifetime prevalence modules. Within the 12-month module, further characteristics of incidents including type of harm, severity of the most serious harm, and additional treatments are analyzed at the event level.
Methods: The study draws on data from a retrospective cross-sectional survey, conducted in 2018 with a nationally representative sample of 10,037 randomly recruited citizens aged ≥40 years. Participants were interviewed about their experiences with incidents using computer-assisted telephone interviews. The sample was weighted according to sociodemographic and spatial characteristics to represent the entire German population aged 40 years and older. Relationships between medical group or specialization and patient-reported incidents were examined using multivariate logistic regression models, controlling for sociodemographic and health-related patient characteristics.
Results: Within the 12-month period prior to the survey, 1,422 participants reported a total of 2,589 incidents. For the lifetime period after the age of 40, 608 individuals reported 748 incidents. In both modules, specialists were implicated in greater portions of incidents (56.3% and 71.4%, respectively) compared to general practitioners (43.7% and 24.2%, respectively). Among the medical fields, orthopedics was the most frequently mentioned, accounting for 14.5% and 19.5% of incidents, respectively. Within the 12-month module, 75% of all incidents were associated with harmful consequences; of these 41% were classified as severe and 35.6% as mild. Multivariate logistic regression revealed significantly elevated OR for severe damage OR=1.39 (95% CI: 1.14-1.70) and very severe damage OR=2.24 (95% CI: 1.64-3.05) among specialists. Across all reported types of damage among all incidents in the last 12 months, physical damage (58%) and time-related damage (46%) were most frequently reported. In multivariate regression analyses, an increased OR was found for financial damage (1.96; 95% CI: 1.51-2.54) and psychological damage (2.08; 95% CI: 1.67-2.60) among specialists. Additional treatment was required in 52.1% of all harmful incidents, with 41.6% necessitating consultations with another physician and 13.2% of cases resulting in hospitalization. The OR of inpatient treatment following incidents among specialists were significantly higher (1.85; 95% CI: 1.36-2.51). On the patient level, associations of the various incident outcomes were observed particularly for female gender, migration background, and poor health status.
Discussion and conclusions: This research paper, embedded within the broader Patient Safety in Ambulatory Care study, represents the first systematic examination of the role of medical specialization in outpatient incidents in Germany. The large, representative sample strengthens the validity and generalizability of the findings. Incidents were more frequently reported among specialists, and the resulting harm was more severe compared to general practitioners. Orthopedics emerged as the most frequently cited medical specialty, aligning with previous literature on patient safety. Several limitations of this study should be considered: the response rate of 12.4% among the target group raises the possibility of selective participation and the associations identified may be artifacts of nonresponse bias; the proportion of variance explained is small and incidents are multifactorial events, meaning that patient's perspective can only capture part of the underlying processes. Moreover, patient-reported incidents don’t necessarily equate to the actual occurrence of medically objectified incidents. Nonetheless, existing research supports the validity of patient reports as a valid source for identifying incidents and potential medical errors, as even the recognition of an error can alter the further course of treatment. Preventing incidents and their harmful consequences in the outpatient sector could significantly reduce the burden on both outpatient and inpatient care. Based on these finding, targeted preventive measures are warranted, particularly in orthopedic and general practice settings, as well as for patient groups identified as being at greater risk, namely women, individuals with a migration background, and those in poor health.
Keywords: Patient safety, ambulatory care, outpatient care, patient safety incidents, general practitioner, medical specialties
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