Based on the IOM's estimate of 44,000 deaths annually, medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human facturs, E.H.R., etc. and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.
Table of Contents
List of Contributors
1 Introduction to Patient Safety and Medical Errors
2 Developing an Outline for Patient Safety Curriculum
3 Understanding System Errors
Section 1 Human Factors Engineering
Clinical Vignette 1: Every Sound Alarms
Clinical Vignette 2: Man and His Machine
Clinical Vignette 3: Expensive Gift
Section 2 Communication Issues
Clinical Vignette 1: Doctors Are from Mars and Nurses Are from Venus!
Clinical Vignette 2: Different Paths Yet the Same Goal
Clinical Vignette 3: It Was Erik’s Fault!
Clinical Vignette 4: You Are Not Alone!
Section 3 Culture of Patient Safety
Clinical Vignette 1: A Husband’s Worst Nightmare
Clinical Vignette 2: A Big No-No
Clinical Vignette 3: Alice in Wonderland
NIDHI SHANKAR KIKKERI, LAURA QI, AND SHIVARAJ NAGALLI
Clinical Vignette 4: A Doctor’s Curse
Clinical Vignette 5: The Real Price of Smoking?
Clinical Vignette 6: A Rainy Night
NIDHI SHANKAR KIKKERI AND LAURA QI
Clinical Vignette 7: Customer Service 101
Clinical Vignette 8: The Empty Crash Cart
Clinical Vignette 9: A Punch in the Face
Clinical Vignette 10: As the Kings So Are the Subjects
Clinical Vignette 11: The Encrypted Message
Section 4 Electronic Medical Records and Patient Safety
Clinical Vignette 1: Rubik’s Cube
Clinical Vignette 2: A Hurried Miss
Clinical Vignette 3: A Case of Mistaken Identity
4 Understanding Diagnostic Errors
Clinical Vignette 1: Is First Love the True Love?
Clinical Vignette 2: Experience Is the Teacher of All Things or Is It?
Clinical Vignette 3: The Man with the Black Coat
Clinical Vignette 4: Don’t Question Me!
Clinical Vignette 5: Trouble with the Curve
Clinical Vignette 6: The New Epidemic
5 Understanding Human/Provider Errors
Clinical Vignette 1: Does Age Bring Wisdom?
Clinical Vignette 2: The Zero-Sum Game
Clinical Vignette 3: Do We Owe our Patients our Lives?
6 Tools and Strategies for Quality Improvement and Patient Safety: A Primer for Healthcare Providers
ANUDEEP YELAM AND RAGHAV GOVINDARAJAN
Raghav Govindarajan, MD is a board certified neurologist and neuromuscular physician with a deep and personal interest in patient safety and medical errors. He was a victim of a medication error which caused long term complications affecting his liver, consequences he still faces today. With this personal experience as well as that of his patients, he has a strong passion for patient safety with particular interest in avoiding communication errors. He is currently an assistant professor and an associate clerkship director of neurology at the University of Missouri. In his current position, he has close interaction with medical students and residents with whom he constantly shares patient safety stories and lessons learned from it. Dr. Govindarajan has a strong background in teaching having won 10 teaching and mentorship awards. He also has been awarded the "Golden Doc" award by the Arnold P. Gold Foundation for providing compassionate and patient-centered care, in addition to the compassionate care award by the Schwartz Foundation. He is the founding member and advisor of Gold Humanism Honor Society at the University of Missouri. Dr. Govindarajan has strong leadership experience having been elected as president-elect of his county medical society and serves as the director of clinical quality improvement and outcomes, physician leader of Clinical Quality Improvement Workgroup and physician leader of the committee. He is the author of numerous articles and case reports in peer-reviewed journals.
Harleen Kaur, MD is a clinical researcher at University of Missouri Columbia, Department of neurology. She has strong passion patient safety and quality improvement which was triggered after experiencing a personal tragic event that affected the care of one of her loved ones. In addition to multiple publications and presentations she has a strong passion for patient centered care.
Anudeep Yelam, MD is a clinical researcher at University of Missouri Columbia, Department of neurology. He has a significant experience working as a volunteer physician in multiple rural hospitals providing care to the underserved population. It is this experience in rural medicine that prompted his interest in developing system based care and use of technology to improve the quality of care in rural settings.