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Quality Grand Rounds: The Case for Patient Safety

2006; American College of Physicians; Volume: 145; Issue: 8 Linguagem: Inglês

10.7326/0003-4819-145-8-200610170-00013

1539-3704

Robert M. Wachter, Kaveh G Shojania, Amy J. Markowitz, Mark D. Smith, Sanjay Saint,

Healthcare cost, quality, practices

Editorials17 October 2006Quality Grand Rounds: The Case for Patient SafetyRobert M. Wachter, MD, Kaveh G. Shojania, MD, Amy J. Markowitz, JD, Mark Smith, MD, MBA, and Sanjay Saint, MD, MPHRobert M. Wachter, MDFrom University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan., Kaveh G. Shojania, MDFrom University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan., Amy J. Markowitz, JDFrom University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan., Mark Smith, MD, MBAFrom University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan., and Sanjay Saint, MD, MPHFrom University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-145-8-200610170-00013 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In this issue, we present the 13th and final article in the Quality Grand Rounds series, the case of an elderly woman admitted to a teaching hospital early in the academic year with a mild episode of acute pancreatitis (1). Despite initial improvement, her condition deteriorated over the course of several days; her ultimate death was attributable to delayed diagnosis and management of a small-bowel obstruction. The case highlights problems in resident supervision, fumbled handoffs, adverse consequences of housestaff duty-hour limitations, and deficient safety systems. As with many cases of medical errors, the explanation is messy and multifaceted, resisting a ...References1. Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy—and occasionally hazardous—intersection. Ann Intern Med. 2006;145:592-8. LinkGoogle Scholar2. Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136:826-33. [PMID: 12044131] LinkGoogle Scholar3. Bates DW. Unexpected hypoglycemia in a critically ill patient. Ann Intern Med. 2002;137:110-6. [PMID: 12118966] LinkGoogle Scholar4. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137:327-33. [PMID: 12204016] LinkGoogle Scholar5. Gerberding JL. Hospital-onset infections: a patient safety issue. Ann Intern Med. 2002;137:665-70. [PMID: 12379067] LinkGoogle Scholar6. Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138:33-9. [PMID: 12513042] LinkGoogle Scholar7. Lynn J, Goldstein NE. Advance care planning for fatal chronic illness: avoiding commonplace errors and unwarranted suffering. Ann Intern Med. 2003;138:812-8. [PMID: 12755553] LinkGoogle Scholar8. Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med. 2003;139:267-73. [PMID: 12965982] LinkGoogle Scholar9. Goldman L, Kirtane AJ. Triage of patients with acute chest pain and possible cardiac ischemia: the elusive search for diagnostic perfection. Ann Intern Med. 2003;139:987-95. [PMID: 14678918] LinkGoogle Scholar10. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025-33. [PMID: 15197020] LinkGoogle Scholar11. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115-20. [PMID: 15657159] LinkGoogle Scholar12. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med. 2005;142:352-8. [PMID: 15738454] LinkGoogle Scholar13. McDonald CJ. Computerization can create safety hazards: a bar-coding near miss. Ann Intern Med. 2006;144:510-6. [PMID: 16585665] LinkGoogle Scholar14. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Pr; 1999. Google Scholar15. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality; July 2001. Accessed at www.ahrq.gov/clinic/ptsafety/ on 11 September 2006. Google Scholar16. Wachter RM. Expected and unanticipated consequences of the quality and information technology revolutions. JAMA. 2006;295:2780-3. [PMID: 16788133] CrossrefMedlineGoogle Scholar17. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293:1197-203. [PMID: 15755942] CrossrefMedlineGoogle Scholar18. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11:104-12. [PMID: 14633936] CrossrefMedlineGoogle Scholar19. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood). 2005;24:138-50. [PMID: 15647225] CrossrefMedlineGoogle Scholar20. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091-7. [PMID: 15964445] CrossrefMedlineGoogle Scholar21. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;353:1405-9. [PMID: 16192489] CrossrefMedlineGoogle Scholar22. Wachter RM, Shojania KG. Internal Bleeding: The Truth behind America's Terrifying Epidemic of Medical Mistakes. New York: Rugged Land; 2004. Google Scholar23. Patient Safety and Quality Improvement Act of 2005. Pub. L. No. 109-41. Accessed at thomas.loc.gov/cgi-bin/bdquery/z?d109:s00544: on 11 September 2006. Google Scholar Author, Article, and Disclosure InformationAffiliations: From University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan.Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation. The authors are supported by general institutional funds.Disclosures: Dr. Wachter is on the Board of Directors of the American Board of Internal Medicine and the Scientific Advisory Boards of Hoana Medical, Codigy, and Intellidot. He has received grants from the Agency for Healthcare Research and Quality. Drs. Wachter and Shojania coauthored the book cited in reference 22.Corresponding Author: Robert M. Wachter, MD, University of California, San Francisco, Box 0120, 505 Parnassus, San Francisco, CA 94143-0120; e-mail, [email protected]ucsf.edu.Current Author Addresses: Dr. Wachter: University of California, San Francisco, Box 0120, 505 Parnassus, San Francisco, CA 94143-0120.Dr. Shojania: Ottawa Health Research Institute, The Ottawa Hospital–Civic Campus, 1053 Carling Avenue, Room C403, Box 693, Ottawa K1Y 4E9, Ontario, Canada.Ms. Markowitz: 527 30th Street, San Francisco, CA 94131.Dr. Smith: California HealthCare Foundation, 476 Ninth Street, Oakland, CA 94607.Dr. Saint: 300 North Ingalls Building, Room 7E08, Campus Box 0429, Ann Arbor, MI 48109-0429. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoGraduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection Kaveh G. Shojania , Kathlyn E. Fletcher , and Sanjay Saint Metrics Cited ByCreating a Culture of Physician Event Reporting Through Resident Physician Education and EngagementThe data of diagnostic error: big, large and smallRepublished: Patients teaching patient safety: the challenge of turning negative patient experiences into positive learning opportunitiesPatients teaching patient safety: the challenge of turning negative patient experiences into positive learning opportunitiesQuality improvement theoriesMisdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processesBrújula para médicos novelesImplementing Patient Safety Interventions in Your Hospital: What to Try and What to Avoid 17 October 2006Volume 145, Issue 8Page: 629-630KeywordsComputersDrug administrationElderlyHealth careNursing administrationPancreatitisPharmacistsPrevention, policy, and public healthResearch quality assessmentSafety ePublished: 17 October 2006 Issue Published: 17 October 2006 CopyrightCopyright © 2006 by American College of Physicians. 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