Improving Patient Safety Tools and Strategies for Quality Improvement

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.

PrefaceEditorsList of Contributors1 Introduction to Patient Safety and Medical ErrorsNAKUL KATYAL2 Developing an Outline for Patient Safety CurriculumNAKUL KATYAL3 Understanding System ErrorsSection 1 Human Factors EngineeringClinical Vignette 1: Every Sound AlarmsDANISH KHERANIClinical Vignette 2: Man and His MachineAHMER ASIFClinical Vignette 3: Expensive GiftANUDEEP YELAMSection 2 Communication IssuesClinical Vignette 1: Doctors Are from Mars and Nurses Are from Venus!TRIPTI CHOPADEClinical Vignette 2: Different Paths Yet the Same GoalTRIPTI CHOPADEClinical Vignette 3: It Was Erik’s Fault!TRIPTI CHOPADEClinical Vignette 4: You Are Not Alone!TRIPTI CHOPADESection 3 Culture of Patient SafetyClinical Vignette 1: A Husband’s Worst NightmareEMILY BAILEYClinical Vignette 2: A Big No-NoEMILY BAILEYClinical Vignette 3: Alice in WonderlandNIDHI SHANKAR KIKKERI, LAURA QI, AND SHIVARAJ NAGALLIClinical Vignette 4: A Doctor’s CurseSUGANIYA SRIKANTHANClinical Vignette 5: The Real Price of Smoking?AHMER ASIFClinical Vignette 6: A Rainy NightNIDHI SHANKAR KIKKERI AND LAURA QIClinical Vignette 7: Customer Service 101KEERTHANA KUMARClinical Vignette 8: The Empty Crash CartKEERTHANA KUMARClinical Vignette 9: A Punch in the FaceSIREESHA MURALAClinical Vignette 10: As the Kings So Are the SubjectsSIREESHA MURALAClinical Vignette 11: The Encrypted MessageKEERTHANA KUMARSection 4 Electronic Medical Records and Patient SafetyClinical Vignette 1: Rubik’s CubeANUDEEP YELAMClinical Vignette 2: A Hurried MissANUDEEP YELAMClinical Vignette 3: A Case of Mistaken IdentityANUDEEP YELAM4 Understanding Diagnostic ErrorsClinical Vignette 1: Is First Love the True Love?HARLEEN KAURClinical Vignette 2: Experience Is the Teacher of All Things or Is It?HARLEEN KAURClinical Vignette 3: The Man with the Black CoatHARLEEN KAURClinical Vignette 4: Don’t Question Me!HARLEEN KAURClinical Vignette 5: Trouble with the CurveHARLEEN KAURClinical Vignette 6: The New EpidemicHARLEEN KAUR5 Understanding Human/Provider ErrorsClinical Vignette 1: Does Age Bring Wisdom?HARLEEN KAURClinical Vignette 2: The Zero-Sum GameHARLEEN KAURClinical 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.