Improving Patient Safety

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.

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.

Preface Editors List of Contributors 1 Introduction to Patient Safety and Medical Errors NAKUL KATYAL 2 Developing an Outline for Patient Safety Curriculum NAKUL KATYAL 3 Understanding System Errors Section 1 Human Factors Engineering Clinical Vignette 1: Every Sound Alarms DANISH KHERANI Clinical Vignette 2: Man and His Machine AHMER ASIF Clinical Vignette 3: Expensive Gift ANUDEEP YELAM Section 2 Communication Issues Clinical Vignette 1: Doctors Are from Mars and Nurses Are from Venus! TRIPTI CHOPADE Clinical Vignette 2: Different Paths Yet the Same Goal TRIPTI CHOPADE Clinical Vignette 3: It Was Erik's Fault! TRIPTI CHOPADE Clinical Vignette 4: You Are Not Alone! TRIPTI CHOPADE Section 3 Culture of Patient Safety Clinical Vignette 1: A Husband's Worst Nightmare EMILY BAILEY Clinical Vignette 2: A Big No-No EMILY BAILEY Clinical Vignette 3: Alice in Wonderland NIDHI SHANKAR KIKKERI, LAURA QI, AND SHIVARAJ NAGALLI Clinical Vignette 4: A Doctor's Curse SUGANIYA SRIKANTHAN Clinical Vignette 5: The Real Price of Smoking? AHMER ASIF Clinical Vignette 6: A Rainy Night NIDHI SHANKAR KIKKERI AND LAURA QI Clinical Vignette 7: Customer Service 101 KEERTHANA KUMAR Clinical Vignette 8: The Empty Crash Cart KEERTHANA KUMAR Clinical Vignette 9: A Punch in the Face SIREESHA MURALA Clinical Vignette 10: As the Kings So Are the Subjects SIREESHA MURALA Clinical Vignette 11: The Encrypted Message KEERTHANA KUMAR Section 4 Electronic Medical Records and Patient Safety Clinical Vignette 1: Rubik's Cube ANUDEEP YELAM Clinical Vignette 2: A Hurried Miss ANUDEEP YELAM Clinical Vignette 3: A Case of Mistaken Identity ANUDEEP YELAM 4 Understanding Diagnostic Errors Clinical Vignette 1: Is First Love the True Love? HARLEEN KAUR Clinical Vignette 2: Experience Is the Teacher of All Things or Is It? HARLEEN KAUR Clinical Vignette 3: The Man with the Black Coat HARLEEN KAUR Clinical Vignette 4: Don't Question Me! HARLEEN KAUR Clinical Vignette 5: Trouble with the Curve HARLEEN KAUR Clinical Vignette 6: The New Epidemic HARLEEN KAUR 5 Understanding Human/Provider Errors Clinical Vignette 1: Does Age Bring Wisdom? HARLEEN KAUR Clinical Vignette 2: The Zero-Sum Game HARLEEN KAUR Clinical Vignette 3: Do We Owe our Patients our Lives? HARLEEN KAUR 6 Tools and Strategies for Quality Improvement and Patient Safety: A Primer for Healthcare Providers ANUDEEP YELAM AND RAGHAV GOVINDARAJAN Index