Narrow Results Clear All
- Error Reporting and Analysis
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
Search results for ""
Journal Article > Study
What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.
Sarkar U, Handley MA, Gupta R, et al. Qual Saf Health Care. 2010;19:223-228.
Adverse events after hospital discharge are a known patient safety hazard, but similar events between ambulatory clinic visits are poorly described. This study longitudinally followed a vulnerable patient population with diabetes between clinic visits and discovered 86% experienced at least one adverse or potential adverse event during the 9-month observation period. Medication management was the most common domain identified, while 80% of all events had a combination of system, clinician, and patient factors contributing. The authors discuss the complex safety environment observed and highlight that patients themselves may be key vehicles for reducing events. A past AHRQ WebM&M interview discusses the challenges in safely caring for vulnerable patient populations in the ambulatory setting.
Journal Article > Review
Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.
This study found little research on safety improvement methods in the primary care of diabetes.
Journal Article > Commentary
Milligan F, Gadsby R, Ghaleb M, et al. Nurs Resid Care. 2014;16:617-621.
Patients in nursing homes are particularly vulnerable to medication errors. Exploring the unique factors that affect medication safety in nursing home residents with diabetes, this review emphasizes the contrasting need to establish a safety culture while promoting incident reporting of errors, which has been inconsistent in this setting due to fear of blame.
Mohr H, Weiss M. Associated Press. November 27, 2018.