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 patien
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.
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 Eriks Fault!
TRIPTI CHOPADE
Clinical Vignette 4: You Are Not Alone!
TRIPTI CHOPADE
Section 3 Culture of Patient Safety
Clinical Vignette 1: A Husbands 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 Doctors 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: Rubiks 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: Dont 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
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.
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