It's funny how in an era of really big events and initiatives something that takes place somewhat off to the side of the stage can cause a few heads to turn momentarily and take notice. Not unlike the first furtive firecracker bang at a Fourth of July celebration before the big show gets going.

Take, for example, a study published in the June 15 issue of the Journal of the American Medical Association showing that while all malpractice claims declined from 2005 to 2009, more than half of the claims paid in 2009 were from the outpatient setting. Good news for hospitals, since it suggests that patient-safety efforts are making headway in institutions. Bad news for hospitals strategizing to network with physician practices and smooth out the continuum of care in general with other providers. Warning ahead? You could be sailing into some choppy patient-safety waters.

The authors acknowledge that malpractice payouts may be a crude indicator, but they are an indicator nonetheless—with serious consequences. We're not talking about offensive doctors with gruff personalities or counting minor mishaps here. "The outcomes of outpatient events were not trivial—major injury or death accounted for almost two-thirds of paid claims for events in the outpatient setting," the authors note. The total tab for outpatient malpractice events came close to ringing the bell at $1.3 billion in 2009.

So, into what big buckets did these errors fall? The most common type of adverse events were classified as diagnostic, 46 percent, followed by treatment at 30 percent and surgical at 14 percent. In contrast, in hospitals, 34 percent were classified as surgical, with diagnostic at 21 percent and treatment at 20 percent.

Knowing how difficult it has been to tackle patient-safety issues in a more or less monolithic institutional setting, not much imagination is needed to envision how difficult it will be in the fractured outpatient setting spread across a gazillion sites with varying "cultures" and resources.

In an understatement, the study suggests that patient-safety initiatives should focus on the outpatient setting, not just inpatient care. And not much help is available now. Experts note that as much as 90 percent of all patient-safety research is on the inpatient side.

One brighter spot: Most agree that IT and EMRs are part of the solution. This year's Most Wired Survey shows that EMR functionalities increased significantly since 2009 in hospital-employed physician practices and crept up slightly in independent practices.

But come what may, hospitals seem set to improve quality and efficiencies across the continuum, partially in response to readmission issues, but also as the right thing to do. And the bigger signposts point in this direction. HHS's Partnership for Patients sweeps in everyone, and the National Quality Forum's proposed expansions to its serious reportable events list for the first time included office practices, ambulatory-surgery centers and skilled-nursing facilities as well as hospitals. Good luck to everybody. And I mean everybody.