A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety.
Approach to Improving Safety
Setting of Care
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.