Introduction: This paper draws on the findings of an in-depth qualitative analysis of a single case of diabetic ketoacidosis, secondary to poor adherence to a patient's prescribed insulin regimen. It sets out to describe the divergent perspectives of a clinician and patient regarding a number of issues. The case is part of a larger ongoing study of the underlying causes of preventable drug-related admissions to hospital, from primary care.

Method: Drug related admissions were identified over a two week period on a Nottingham, medical admissions ward and assessed using a previously validated methodology.1 Inclusion criteria were patients admitted as a result of preventable adverse drug reactions, under-treatment of a known condition, or poor patient adherence to prescribed medication. In-depth interviews with patients, GPs, and pharmacists were conducted to elicit views on the underlying causes of hospital admissions, and analysed using qualitative methodolody.2

Findings: Transcripts of interviews with the GP and patient revealed divergence in their perspectives on the underlying causes and preventability of the hospital admission.

Problems with diabetic management: The patient felt that financial problems caused by the loss of his "disability living allowance" (DLA), which he attributed to a report written by his GP, and the impact of this on his family and personal circumstances, put severe strain on his ability to cope with everyday life and his diabetes.
The GP stated that the patient had a long-term 'personality deficit' which makes it difficult for him to manage everyday life and his diabetes. He was unaware of the patients' financial difficulties and the impact of this on his life and diabetic control.

Problems with the patient-GP relationship: The patient expressed a loss of trust in the GP following the DLA report, which resulted in a breakdown in the GP-Patient relationship. The GP was unaware of the breakdown in their relationship.

Preventability of the patient admission: The patient was convinced that the hospital admission was preventable. He felt that future admissions could be avoided by greater financial support, and better understanding of his situation by health care professionals. Although the GP felt that the hospital admission was foreseeable, he did not feel that it was preventable from his perspective.

Responsibility for monitoring diabetic control: The interview with the GP revealed a lack of clarity about whose responsibility it was to monitor a patient's diabetic control: the practice, the hospital or the patient.

Conclusions: There are limitations to the generalisability of a single case study. However, we believe there are important lessons to be learned from this case.
From the transcripts, it was apparent that there was little overlap between the GPs and patients accounts of the underlying causes, and preventability of this admission, associated with a lack of meaningful dialogue between the two parties.
This case highlights the importance of patient-centred care in diabetes management3 in preventing drug related hospital admissions.

References
1. Howard R, Avery A, Howard P et al. Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study. Qual Saf Health Care 2003; 12: 280-285.
2. Mason J. Qualitative researching. Sage Publications, London, 1996.
3. Type 1 diabetes: management of diabetes in adults in primary and secondary care. First Draft for consultation. Available from www.nice.org.uk. (accessed 6th October 2003).