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Journal Article > Study
Buetow S, Kiata L, Liew T, Kenealy T, Dovey S, Elwyn G. Ann Fam Med. 2009;7:223-231.
Preliminary research has found that patient factors may contribute to errors—for example, when the patient fails to take medications as prescribed. In this study, focus groups of patients and health care professionals were used to identify and characterize the types of errors that can be committed by patients. The authors identified two main groups of errors: action errors, errors of patient behavior such as failing to attend an appointment, and mental errors, which are errors of patients' thought processes. Included among mental errors are factors that have been linked to errors, such as low health literacy. The authors suggest that further research should investigate how interactions among patients, clinicians, and systems lead to harmful adverse events.
Journal Article > Commentary
Sarkar U, Wachter RM, Schroeder SA, Schillinger D. Jt Comm J Qual Patient Saf. 2009;35:377-383.
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.
Special or Theme Issue
Paasche-Orlow MK, Wilson EAH, McCormack L, eds. J Health Comm. 2010;15(suppl 2):1-225.
This special issue presents findings from a 2009 conference that explored health literacy research in areas such as measurement improvement, informed consent, and organizational communication.