1st Edition

Improving Patient Safety Tools and Strategies for Quality Improvement

    298 Pages 15 B/W Illustrations
    by Productivity Press

    298 Pages 15 B/W Illustrations
    by Productivity Press

    298 Pages 15 B/W Illustrations
    by Productivity Press

    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 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

    Biography

    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.