title: What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.
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.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California 94143-1364, USA. usarkar@medicine.ucsf.edu
authors.forename: Urmimala
authors.initials: U
authors.lastname: Sarkar
authors.forename: M A
authors.initials: MA
authors.lastname: Handley
authors.forename: R
authors.initials: R
authors.lastname: Gupta
authors.forename: A
authors.initials: A
authors.lastname: Tang
authors.forename: E
authors.initials: E
authors.lastname: Murphy
authors.forename: H K
authors.initials: HK
authors.lastname: Seligman
authors.forename: K G
authors.initials: KG
authors.lastname: Shojania
authors.forename: D
authors.initials: D
authors.lastname: Schillinger
mesh_terms: D000553:Ambulatory Care / Q000379:methods* / Q000592:standards*; D003142:Communication; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000628:therapy*; D006801:Humans; D055118:Medication Adherence; D009819:Office Visits; D010353:Patient Education as Topic / Q000379:methods*; D010817:Physician-Patient Relations; D011203:Poverty; D012648:Self Care / Q000379:methods*; D013689:Telephone; D014505:Urban Population