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Adverse events between visits for patients with diabetes mellitus Adverse events between ambulatory patient visits are increasingly the focus of study. By means of an automated telephone self-management tool, 111 patients with diabetes mellitus were monitored for adverse events between visits in the course of their home management. Of note, the study population was ethnically and linguistically diverse, and most had longstanding and poorly controlled diabetes. Among these patients, 86% had at least one event detected over a 9-month study period totalling 111 adverse events and an additional 153 potential adverse events. Medication management was implicated as the dominant adverse event and constituted 63% of events. Of note inadequate clinician-patient communication was implicated in 59%. In fully 80% of all events, a combination of system, clinician and patient factors contributed to the adverse event. The authors suggest that patient-level self-management support and patient-centred communication offer the greatest opportunities for prevention of adverse events in this setting. See page 223