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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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The Many Roads to Medication Adherence

Posted By Administration, Tuesday, November 15, 2016

Medication adherence is a major challenge, particularly in outpatient settings.
We need a multipronged approach to improvement.

By Tejal K. Gandhi, MD, MPH, CPPS


Tejal K. Gandhi

Last month in this column I wrote about the importance of addressing patient safety across the continuum of care. As an example of how challenging this is, let’s take a look at one aspect of outpatient safety: medication adherence.

Medication adherence problems are not simply a matter of patients accidentally missing a dose. Primary nonadherence occurs when patients do not take the step of filling or picking up a prescription. But nonadherence also includes taking a lower or higher dose than prescribed; stopping a prescription early; taking an old medication for a new problem without consulting a doctor; taking medication prescribed for someone else; and forgetting whether a medication has been taken.

These are major problems in the ambulatory arena, where patients or their family members serve the vital role of administering medication.

Most health professionals recognize the challenges involved when patients do not take medications as directed—or at all—whether intentionally or unintentionally. In one study of 195,000 newly prescribed e-prescriptions, only 72% were filled. Nonadherence was common for medications for chronic conditions such as hypertension, diabetes, and hyperlipidemia.


When medication is not taken as prescribed, health problems may worsen, requiring more intervention. Nonadherence not only poses risks to patients’ health, it also costs our health care system an estimated $100 billion annually in avoidable hospitalizations.

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Medication Adherence in Practice

The issue of not taking medications—and how to improve it—is linked to several major themes in patient safety:

  1. Patient and family engagement. As noted in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, most definitions of patient engagement include ideas such as partnership, communication, information exchange, and respect. Health care practitioners can help improve adherence by making sure patients understand why the medication has been prescribed and how to take it properly, and by answering questions and addressing concerns.

  2. Health literacy. More than one-third of US adults have below basic or basic health literacy skills. Health literacy involves the ability to not only read and follow instructions, but also work with numbers and understand what to do if something goes wrong, if a dose is missed, or if an adverse event occurs.

  3. Transitions in care. Patients recently discharged face challenges in adhering to medication regimens that may have changed since they entered the hospital. In one study, 29% of patients were not taking a medication on their discharge list, were taking a different does or frequency, or taking an additional medication.

There is no easy solution and, in fact, a multipronged approach is likely needed to improve medication adherence. Zullig and colleagues note that greater research and evaluation of strategies, similar to the drug development process, is needed to encourage adherence. Furthermore, they note that the success of each strategy may differ between patient populations and settings, and that efforts are needed for wide dissemination and adoption of proven interventions.


Other interventions are currently being tested:

  • Mobilizing pharmacists to answer patients’ questions and be sure they know how to take medication properly.
  • Encouraging the use of patient portals by patients to become familiar with their medications, order refills, or ask questions.
  • Exploring pill monitoring technology, such as electronic pill caps and “smart” blister packaging.
  • Using innovative options such as electronic monitors (for example, biometric monitors or activity monitors) and mobile health strategies (such as text messaging and smartphone apps) to alert health practitioners about medication adherence and remind patients to take their medication. One of the eight recommendations of the NPSF Free from Harm report is to ensure that technology is safe and optimized to improve patient safety. There is much promise in the drive to use technology to improve medication adherence.

We still have work to do to determine the best strategies to improve this area of patient safety, and we need to match interventions to each patient’s individual needs. But we are at a point where innovations in technology, coupled with increased education among providers about the issue, may converge to help improve medication adherence across the continuum of care.

What strategies do you think will encourage medication adherence? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  ambulatory  medication  patient engagement 

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Patients, Patients—Everywhere

Posted By Administration, Friday, October 14, 2016

Why we must improve patient safety in all settings.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


According to publicly reported data, about half of all adults in the U.S. have a chronic illness, 60% take at least one prescription medication, and more than 1 billion health care encounters take place each year in ambulatory settings such as doctor’s offices, emergency departments, and hospital-based outpatient clinics. By comparison, there are roughly 35 million hospital admissions in the U.S. each year.


Despite the much greater utilization of outpatient health services, patient safety research and advances have largely taken place in hospitals. Today, when only the very sickest patients are hospitalized, and many patients with chronic illnesses are treated in ambulatory care or even in the home, it is past time to focus research dollars and efforts toward the epidemiology of medical errors, lapses, and near misses in other settings, and in finding solutions to effectively prevent them.

What do we know about medical errors in outpatient care? A 2011 study that looked at paid medical malpractice claims found that 43% of the events took place in ambulatory settings, and another 9% involved both inpatient and outpatient settings. The most common reason for a paid claim in outpatient care was for misdiagnosis, and the most common outcomes in either setting were “major injury” and “death.”

Outcomes associated with malpractice claims may be the most shocking, but they are far from the only instances of safety lapses. A systematic review of patient safety incidents in primary care published earlier this year found that errors occur fairly frequently, although most do not result in serious harm. Medication errors and diagnostic errors were found to be most common, but the authors note that lack of a “standardized taxonomy for classifying incidents and harm” make it difficult to compare results across settings and over time.

About 9 million people in the U.S. receive home health care or care in nursing homes, rehabilitation centers, and other residential care facilities. The lack of care coordination between these settings and the risk of miscommunication or lack of communication between providers is another gaping opportunity for error. A 2014 analysis by the Department of Health & Human Services Office of the Inspector General (OIG) reviewed records of Medicare patients who transitioned from acute care hospitals to skilled nursing facilities. According to the OIG report, 22% of the patients sampled experienced an adverse event with serious harm, and another 11% experienced temporary harm. Physician reviewers determined that 59% of the events and harms were “clearly or likely preventable.”

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Safety in home care is another largely unexplored territory. According to the Family Caregiver Alliance, in 2015, some 43 million people provided care to an adult or child in the U.S. Unlike a hospital or physician’s office, a patient’s home is an uncontrolled environment with unique hazards that can potentially harm both the patient and the home health care worker or family caregiver.

We are only at the very beginning stages of grasping how to address patient safety under these circumstances, and the need for improvement grows in proportion to our aging population.

Addressing safety across the care continuum is among the key recommendations of an NPSF report released late last year. In order to advance safety in all settings we need to better understand the epidemiology of medical errors and safety lapses in those settings, which will require more funding for research and creation of better metrics for tracking and improvement.

In addition, while most hospitals today have patient safety officers, departments, or committees, many outpatient and residential care facilities lack the infrastructure and expertise so necessary to make improvements. The NPSF report recommends expanding safety expertise, reporting mechanisms, collaboratives for sharing experiences and insights, and other methods of identifying and implementing best practices for all settings across the care continuum.

Of course, this is easier said than done. I have written here recently about the importance of federal funding for the Agency for Healthcare Research and Quality, which does so much to support patient safety research. But we also need health care leaders to recognize the importance of safety issues in all settings and prioritize developing the safety science and expertise to drive improvement.

What are your ideas for improving patient safety across the continuum of care? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  ambulatory 

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