California's Medicaid pay-for-performance program requires safety-net health care systems to report and improve upon diverse ambulatory safety measures. Researchers found that participating safety-net hospitals struggled to report accurate data. Systems had more success improving metrics that placed patients at risk of life-threatening harm when compared to metrics that required longer term follow-up or patient engagement.

Although patients with limited English proficiency had worse understanding of their hospital discharge instructions compared with patients fluent in English, comprehension of discharge instructions was poor among all patients regardless of language ability.

While the patient safety field originated in studies of error in hospitals, safety in ambulatory care remains relatively less studied. Even within ambulatory safety, few studies address safety issues in chronic disease management, despite the fact that most medical care is provided in this context. In this article, the authors use evidence and case vignettes to develop a conceptual model of ambulatory safety and discuss how this model differs from the classic Donabedian triad. The framework emphasizes the role of health systems (including care coordination and information technology) and patient factors (such as health literacy) as determinants of safety and health outcomes.

Chronic disease care increasingly involves patients engaging in self-management activities outside of discrete clinical encounters—for example, diabetics must monitor their blood sugars at home. This study used retrospective analysis of data from an interactive telephone-based diabetes self-management system to characterize the types and severity of adverse events occurring between physician visits in a low health literacy patient population. The vast majority of patients experienced at least one adverse event, most of which were considered preventable. Most events were detected by prompts generated by the telephone-based system. This study is one of the first to address adverse events in ambulatory patients outside the context of clinician visits and provides a model for addressing patient safety in chronic disease management.

Prevention of medication errors remains a focus of patient safety efforts, with warfarin use posing unique challenges, particularly for patients. This study used a visual medication schedule at each patient visit, coupled with brief counseling, to improve the time to reach anticoagulation control. For patients with a poor understanding of their warfarin regimen, investigators discovered significant benefits from the intervention, with nearly a 2-week difference in reaching a therapeutic goal. While similar benefit did not occur in those with good understanding of their regimen and the study was not powered to determine the role of health literacy on such understanding, the authors point out the value of this simple strategy to enhance warfarin safety for at-risk patients.

The researchers examined patient adherence to a warfarin regimen and concordance between the patient's regimen and physician's report. They found that miscommunication may contribute to under- and overanticoagulation.