Sarkar Urmimala, Handley M A, Gupta R, Tang A, Murphy E, Seligman H K, Shojania K G, Schillinger D
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.
Qual Saf Health Care. 2010 Jun;19(3):223-8. doi: 10.1136/qshc.2008.029116. Epub 2010 Apr 8.
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.
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.
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%).
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.
对于门诊慢性病患者在两次就诊之间发生的不良事件（AE），我们了解甚少。为不同人群的糖尿病患者实施了一项自动化电话自我管理支持计划，以捕捉不良事件，描述其产生的自我管理领域，并探究促成因素。
在111名不同种族的糖尿病患者中识别不良事件和潜在不良事件（PotAE）。不良事件是指由医疗管理或患者自我管理导致的损伤；潜在不良事件是指一种不安全状态，如果持续存在且不加以干预，可能会导致不良事件发生。通过查阅病历以确定事件涉及哪个自我管理领域，并探究促成因素。
在111名患者中，86%在9个月的观察期内至少检测到一次事件。共识别出111起不良事件和153起潜在不良事件。对于所有事件，药物管理是最常见的领域（166起事件，占63%）。只有20%的事件反映单一促成因素；在其余80%的事件中，系统、临床医生和患者因素共同导致事件发生。患者行为与205起（77%）事件有关，系统问题与183起（69%）事件有关，医患沟通不足与155起（59%）事件有关。除沟通外，基层医疗临床医生的行为仅在16例（6%）事件中促成事件发生。
我们的研究结果揭示了一个复杂的安全生态，门诊糖尿病患者的不良事件和潜在不良事件存在多种促成因素。此外，患者自身似乎是安全和不良事件的关键驱动因素，这表明患者层面的自我管理支持和以患者为中心的沟通对于预防不良事件至关重要。
