OBJECTIVE: Outpatient drug complications have not been well studied. We sought to assess the incidence and characteristics of outpatient drug complications, identify their clinical and nonclinical correlates, and evaluate their impact on patient satisfaction. DESIGN:Retrospective chart reviews and patient surveys. SETTING: Eleven Boston-area ambulatory clinics. PATIENTS:We randomly selected 2,248 outpatients, 20 to 75 years old. MEASUREMENTS AND MAIN RESULTS:Among 2,248 patients reporting prescription drug use, 394 (18%) reported a drug complication. In contrast, chart review revealed an adverse drug event in only 64 patients (3%). In univariate analyses, significant correlates of patient-reported drug complications were number of medical problems, number of medications, renal disease, failure to explain side effects before treatment, lower medication compliance, and primary language other than English or Spanish. In multivariate analysis, independent correlates were number of medical problems (odds ratio T herapeutic drugs are a core component of the practice of medicine; 75% of office visits to primary care providers involve the initiation or continuation of drug therapy. 1 Adverse drug events (ADEs), defined as injuries due to drugs, occur commonly in the hospital setting. In the ADE Prevention Study, ADEs occurred at a rate of 6.5 per 100 admissions, and 28% of these events were preventable. 2 Many other studies have also been done to characterize inpatient ADEs. [3][4][5][6] Data suggest that ADEs among outpatients are an important problem as well. A recent meta-analysis suggested that in 1994 more than 1 million outpatients in the United States experienced an ADE that required admission to the hospital, and that 4.7% of admissions were caused by drugs. 7 The study also suggested that there were 106,000 fatal ADEs in the United States in 1994, which would place them between the fourth and sixth leading causes of death, although these projections may be high. 8 A recent study of U.S. death certificates showed that the number of people who reportedly died from medication errors increased by 2. 5-fold from 1983 to 1993, 9 suggesting that the problem may be worsening. However, compared with the inpatient setting, there is relatively little information about ADEs in the ambulatory setting. Estimates of the proportion of outpatients experiencing an ADE per year have ranged from 5% to 35%. 10,11 Several reasons exist for the relative lack of information about ADEs in the ambulatory setting. In contrast to inpatients, outpatients are responsible for both obtaining and administering their medications. Therefore, the process is much less controlled. Also, physicians have less regular contact with outpatients and are less likely to hear about their problems. Chart review also has limitations related to high costs and inadequate documentation. 12 Therefore, previous studies of outpatients have relied heavily on patient report, which has inherent limitations. Dependence on patients' recall during interviews or on re-[
Objectives: To estimate the proportion and characteristics of patients injured by medical care in New Zealand public hospitals who complain to an independent health ombudsman, the Health and Disability Commissioner (''the Commissioner''). Design: The percentage of injured patients who lodge complaints was estimated by linking the Commissioner's complaints database to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses investigated sociodemographic and socioeconomic differences between complainants and non-complainants. Setting: New Zealand public hospitals and the Office of the Commissioner in 1998. Population: Patients who lodged claims with the Commissioner (n = 398) and patients identified by the NZQHS as having suffered an adverse event who did not lodge a complaint with the Commissioner (n = 847). Main outcome measures: Adverse events, preventable adverse events, and complaints lodged with the Commissioner. Results: Among adverse events identified by the NZQHS, 0.4% (3/850) resulted in complaints; among serious, preventable adverse events 4% (2/48) resulted in complaints. The propensity of injured patients to complain increased steeply with the severity of the injury: odds of complaint were 11 times greater after serious permanent injuries than after temporary injuries, and 18 times greater after deaths. Odds of complaining were significantly lower for patients who were elderly (odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1 to 0.4), of Pacific ethnicity (OR 0.3, 95% CI 0.1 to 0.9), or lived in the most deprived areas (OR 0.3, 95% CI 0.2 to 0.6). Conclusion: Most medical injuries never trigger a complaint to the Commissioner. Among complaints that are brought, severe and preventable injuries are common, offering a potentially valuable ''window'' on serious threats to patient safety. The relatively low propensity to complain among patients who are elderly, socioeconomically deprived, or of Pacific ethnicity suggests troubling disparities in access to and utilisation of complaints processes.
To evaluate the impact of patient characteristics and method of data collection on satisfaction results used for the comparison of practice locations, questionnaires were distributed to 1,208 adult outpatients at five medicine clinics, either on-site or by mail. Patient dissatisfaction with three service domains was measured: communication with the provider, courtesy of the office staff, and timeliness of care. Practice location, survey methodology, and patient characteristics were significant predictors of dissatisfaction, and adjustment for the latter two factors affected the rankings of practices by dissatisfaction rates for all three domains. Further study of the impact of patient characteristics and method of data collection should be conducted before the comparison of unadjusted satisfaction results becomes the accepted standard.
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