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Qual Saf Health Care doi:10.1136/qshc.2008.029116
  • Original research

What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes

  1. D Schillinger1
  1. 1Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California, USA
  2. 2Department of Epidemiology and Biostatistics and Division of General Internal Medicine, University of California, San Francisco Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California, USA
  3. 3Department of Medicine, University of California, San Francisco, San Francisco, California, USA
  4. 4Department of Public Health, San Francisco, California, USA
  5. 5Division of Endocrinology, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
  6. 6Department of Medicine, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  1. Correspondence to Urmimala Sarkar, Division of General Internal Medicine, University of California, San Francisco, Box 1364, San Francisco, CA 94143-1364, USA; usarkar{at}medicine.ucsf.edu
  • Accepted 13 April 2009
  • Published Online First 8 April 2010

Abstract

Background Little is known about adverse events (AEs) that occur between physician visits for ambulatory chronic disease patients. An automated telephone self-management support programme for a diverse population of diabetes patients was implemented to capture AEs, describe the self-management domains from which they emanate and explore contributing causes.

Methods AEs and potential AEs (PotAEs) were identified among 111 ethnically diverse diabetes patients. An AE is an injury that results from either medical management or patient self-management; a PotAE is an unsafe state likely to lead to an event if it persists without intervention. Medical record reviews were conducted to ascertain which self-management domain was involved with the event and to explore contributing causes.

Results Among the 111 patients, 86% had at least one event detected over the 9-month observation period. 111 AEs and 153 PotAEs were identified. For all events, medication management was the most common domain (166 events, 63%). Only 20% of events reflected a single contributing cause; in the remaining 80%, a combination of system, clinician and patient factors contributed to their occurrence. Patient actions were implicated in 205 (77%) events, systems issues in 183 (69%) events and inadequate physician–patient communication in 155 (59%) events. Aside from communication, primary care clinician actions contributed to the occurrence of the event in only 16 cases (6%).

Conclusions Our findings reveal a complex safety ecology, with multiple contributing causes for AEs and PotAEs among ambulatory diabetes patients. Moreover, patients themselves seem to be key drivers of safety and of AEs, suggesting that patient-level self-management support and patient-centred communication are critical to AE prevention.

Footnotes

  • Funding US is supported by Agency for Healthcare Research and Quality K08 HS017594. Support for this research was also provided by The Commonwealth Fund and The California Health Care Foundation. The views presented here are those of the authors and should not be attributed to The Commonwealth Fund, California Health Care Foundation, or their directors, officers or staff. DS and MAH were also supported by grants from Agency for Healthcare Research and Quality R21 HS014864 and Agency for Healthcare Research and Quality R18 HS01726101. Electronic data were made available through the support of NIH grant UL1 RR024131. KGS received salary support from the Government of Canada Research Chairs Program. Other Funders: NIH.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the University of California, San Francisco, San Francisco General Hospital.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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