The purpose of this book is to provide nurses with the best available research, thereby enabling better decisions that result in improved health care and safety practices and lead to better outcomes. Nurses often are the ones who find errors and prevent pa tient harm. In their focus on patient safety, nurses identify critical issues and research for evidence-based practice. This book is a great resource for practicing nurses, nurse educators, re searchers, leaders, and students. The Agency for Healthcare Research and Quality strongly promotes that safety and quality of health care is dependent on the availability of the best research possible and the ability to deliver results of research into the hands of practitioners, policy makers, and consumers. This text is a culmination of subject expert knowledge, practice, and research from 89 contributors who represent a broad range of nurses and senior researchers across the nation. The topics covered in this text provide excellent background for any clinician, nurse educator, or nurse leader. The topics include • evidence-based practice, • patient-centered care, • working environment for nurses, • care models, and • patient acuity. The chapters provide an easy-tounderstand guide and include a background section and analysis of the literature based on the topic presented. Practice implications are identified at the end of each chapter and guide efforts for improving quality and patient care. Research implications for each topic outline target areas for improvement and can be used by clinicians to inform and guide practice. There are also questions and issues to develop or expand thesis topics and research papers, which faculty members may find useful. A section on critical opportunities contains current topics, including wrong site surgery, communication hand offs by nurses, medication administration safety, medication reconciliation, and personal safety for nurses. These topics are very well presented with numerous research citations and examples from all areas of nursing— from patient entry to the facility to discharge and home care. The authors use exhibits, tables, guides, templates, models, and representations within each chapter and conclude with a list of references including web sites for further independent review and citation. The volumes are written in a manner that allows for quick access, and they are

Patient Safety and Quality: An Evidence-Based Handbook for Nurses

OBJECTIVE —The purpose of this study was to determine the extent to which patients omit doses of medications prescribed for diabetes. RESEARCH DESIGN AND METHODS —A literature search (1966–2003) was performed to identify reports with quantitative data on adherence with oral hypoglycemic agents (OHAs) and insulin and correlations between adherence rates and glycemic control. Adequate documentation of adherence was found in 15 retrospective studies of OHA prescription refill rates, 5 prospective electronic monitoring OHA studies, and 3 retrospective insulin studies. RESULTS —Retrospective analyses showed that adherence to OHA therapy ranged from 36 to 93% in patients remaining on treatment for 6–24 months. Prospective electronic monitoring studies documented that patients took 67–85% of OHA doses as prescribed. Electronic monitoring identified poor compliers for interventions that improved adherence (61–79%; P CONCLUSIONS —This review confirms that many patients for whom diabetes medication was prescribed were poor compliers with treatment, including both OHAs and insulin. However, electronic monitoring systems were useful in improving adherence for individual patients. Similar electronic monitoring systems for insulin administration could help healthcare providers determine patients needing additional support.

https://care.diabetesjournals.org/content/diacare/27/5/1218.full.pdf

A Systematic Review of Adherence With Medications for Diabetes

Wens et al. (1) comment on the value of using multiple databases to search the literature for my report (2). However, they do not mention another technique that I have found to be valuable: checking the reference lists of articles found in database searches and other sources. This manual method overcomes …

https://care.diabetesjournals.org/content/diacare/27/9/2285.1.full.pdf

A Systematic Review of Adherence With Medications for Diabetes: Response to Wens et al.

Competency-based medical education (CBME), by definition, necessitates a robust and multifaceted assessment system. Assessment and the judgments or evaluations that arise from it are important at the level of the trainee, the program, and the public. When designing an assessment system for CBME, medical education leaders must attend to the context of the multiple settings where clinical training occurs. CBME further requires assessment processes that are more continuous and frequent, criterion-based, developmental, work-based where possible, use assessment methods and tools that meet minimum requirements for quality, use both quantitative and qualitative measures and methods, and involve the wisdom of group process in making judgments about trainee progress. Like all changes in medical education, CBME is a work in progress. Given the importance of assessment and evaluation for CBME, the medical education community will need more collaborative research to address several major challenges in assessment, including ‘‘best practices’’ in the context of systems and institutional culture and how to best to train faculty to be better evaluators. Finally, we must remember that expertise, not competence, is the ultimate goal. CBME does not end with graduation from a training program, but should represent a career that includes ongoing assessment.

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The role of assessment in competency-based medical education

Complex environmental, social, behavioral, and emotional factors, known as psychosocial factors, influence living with diabetes, both type 1 and type 2, and achieving satisfactory medical outcomes and psychological well-being. Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life. To promote optimal medical outcomes and psychological well-being, patient-centered care is essential, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (1). Practicing personalized, patient-centered psychosocial care requires that communications and interactions, problem identification, psychosocial screening, diagnostic evaluation, and intervention services take into account the context of the person with diabetes (PWD) and the values and preferences of the PWD.

This article provides diabetes care providers with evidence-based guidelines for psychosocial assessment and care of PWD and their families. Recommendations are based on commonly used clinical models, expert consensus, and tested interventions, taking into account available resources, practice patterns, and practitioner burden. Consideration of life span and disease course factors (Fig. 1) is critical in the psychosocial care of PWD. This Position Statement focuses on the most common psychological factors affecting PWD, including diabetes distress and psychological comorbidities, while also considering the needs of special populations and the context of care.



Figure 1 
Psychosocial care for PWD: life and disease course perspectives. *With depressed mood, anxiety, or emotion and conduct disturbance. **Personality traits, coping style, maladaptive health behaviors, or stress-related physiological response. \***|Examples include changing schools, moving, job/occupational changes, marriage or divorce, or experiencing loss.



#### Recommendations

https://care.diabetesjournals.org/content/diacare/39/12/2126.full.pdf

Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association

OBJECTIVE —Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population. RESEARCH DESIGN AND METHODS —The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA 1c determination during the study period. Multiple linear regression was used to examine the association of HbA 1c level as well as change in HbA 1c level with medication adherence, demographic, and clinical characteristics. RESULTS —Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA 1c decreased by 0.16% ( P 1c of African-Americans was 0.29% higher than that of whites ( P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA 1c testing, or continuity of care. CONCLUSIONS —Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.

https://care.diabetesjournals.org/content/diacare/25/6/1015.full.pdf

The association between diabetes metabolic control and drug adherence in an indigent population.

BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis. OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting. DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice. SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year. MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period. CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

Patient Safety in the Ambulatory Setting: A Clinician-based Approach

Improving patient safety and quality in health care is one of medicine's most pressing challenges. Residency training programs have a unique opportunity to meet this challenge by training physicians in the science and methods of patient safety and quality improvement (QI).With support from the Health Resources and Services Administration, the authors developed an innovative, longitudinal, experiential curriculum in patient safety and QI for internal medicine residents at the University of Virginia. This two-year curriculum teaches the critical concepts and skills of patient safety and QI: systems thinking and human factors analysis, root cause analysis (RCA), and process mapping. Residents apply these skills in a series of QI and patient safety projects. The constructivist educational model creates a learning environment that actively engages residents in improving the quality and safety of their medical practice.Between 2003 and 2005, 38 residents completed RCAs of adverse events. The RCAs identified causes and proposed useful interventions that have produced important care improvements. Qualitative analysis demonstrates that the curriculum shifted residents' thinking about patient safety to a systems-based approach. Residents completed 237 outcome assessments during three years. Results indicate that seminars met predefined learning objectives and were interactive and enjoyable. Residents strongly believe they gained important skills in all domains.The challenge to improve quality and safety in health care requires physicians to learn new knowledge and skills. Graduate medical education can equip new physicians with the skills necessary to lead the movement to safer and better quality of care for all patients.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Mohan M. Nadkarni

Papers

The association between diabetes metabolic control and drug adherence in an indigent population.

Patient Safety in the Ambulatory Setting: A Clinician-based Approach

Changing conversations: teaching safety and quality in residency training.

Determinants of physician use of an ambulatory prescription expert system.

Free clinics: a national survey.