Improving Patient Safety: Tools and Strategies for Quality Improvement

299 Pages·2019·4.767 MB·\299

by  Raghav Govindarajan (Author)

Improving Patient Safety

Improving Patient Safety
Tools and Strategies for Quality
Improvement
Edited by
Raghav Govindarajan, MD
Harleen Kaur, MD
Anudeep Yelam, MD
First edition published in 2019
by Routledge/Productivity Press
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Contents
Preface ........................................................................................................ix
Editors ........................................................................................................xi
List of Contributors ................................................................................xiii
1 Introduction to Patient Safety and Medical Errors ......................1
NAKUL KATYAL
2 Developing an Outline for Patient Safety Curriculum .................7
NAKUL KATYAL
3 Understanding System Errors ....................................................13
Section 1 Human Factors Engineering .....................................14
Clinical Vignette 1: Every Sound Alarms .................................................14
DANISH KHERANI
Clinical Vignette 2: Man and His Machine...............................................20
AHMER ASIF
Clinical Vignette 3: Expensive Gift ...........................................................32
ANUDEEP YELAM
Section 2 Communication Issues ..............................................38
Clinical Vignette 1: Doctors Are from Mars and Nurses Are
from Venus! ...............................................................................................38
TRIPTI CHOPADE
Clinical Vignette 2: Different Paths Yet the Same Goal ...........................54
TRIPTI CHOPADE
Clinical Vignette 3: It Was Erik’s Fault! .....................................................71
TRIPTI CHOPADE
Clinical Vignette 4: You Are Not Alone! ...................................................85
TRIPTI CHOPADE
v
vi ◾ Contents
Section 3 Culture of Patient Safety ...........................................95
Clinical Vignette 1: A Husband’s Worst Nightmare ..................................95
EMILY BAILEY
Clinical Vignette 2: A Big No-No ............................................................100
EMILY BAILEY
Clinical Vignette 3: Alice in Wonderland ...............................................106
NIDHI SHANKAR KIKKERI, LAURA QI, AND SHIVARAJ NAGALLI
Clinical Vignette 4: A Doctor’s Curse .....................................................118
SUGANIYA SRIKANTHAN
Clinical Vignette 5: The Real Price of Smoking? ....................................124
AHMER ASIF
Clinical Vignette 6: A Rainy Night ..........................................................140
NIDHI SHANKAR KIKKERI AND LAURA QI
Clinical Vignette 7: Customer Service 101 ..............................................149
KEERTHANA KUMAR
Clinical Vignette 8: The Empty Crash Cart ............................................158
KEERTHANA KUMAR
Clinical Vignette 9: A Punch in the Face ...............................................164
SIREESHA MURALA
Clinical Vignette 10: As the Kings So Are the Subjects .........................171
SIREESHA MURALA
Clinical Vignette 11: The Encrypted Message ........................................176
KEERTHANA KUMAR
Section 4 Electronic Medical Records and Patient Safety
Clinical Vignette 1: Rubik’s Cube ...........................................................182
ANUDEEP YELAM
Clinical Vignette 2: A Hurried Miss ........................................................188
ANUDEEP YELAM
Clinical Vignette 3: A Case of Mistaken Identity ...................................191
ANUDEEP YELAM
4 Understanding Diagnostic Errors ............................................195
Clinical Vignette 1: Is First Love the True Love? ....................................196
HARLEEN KAUR
Contents ◾ vii
Clinical Vignette 2: Experience Is the Teacher of All Things or Is It? ......203
HARLEEN KAUR
Clinical Vignette 3: The Man with the Black Coat ................................211
HARLEEN KAUR
Clinical Vignette 4: Don’t Question Me! .................................................218
HARLEEN KAUR
Clinical Vignette 5: Trouble with the Curve ...........................................223
HARLEEN KAUR
Clinical Vignette 6: The New Epidemic .................................................230
HARLEEN KAUR
5 Understanding Human/Provider Errors ..................................237
Clinical Vignette 1: Does Age Bring Wisdom? .......................................238
HARLEEN KAUR
Clinical Vignette 2: The Zero-Sum Game ..............................................245
HARLEEN KAUR
Clinical Vignette 3: Do We Owe our Patients our Lives? ......................254
HARLEEN KAUR
6 Tools and Strategies for Quality Improvement and Patient
Safety: A Primer for Healthcare Providers ..............................263
ANUDEEP YELAM AND RAGHAV GOVINDARAJAN
Index ..............................................................................................275

Preface
M
edical errors are considered as one of the major factors affecting
patient safety in the healthcare system. They are the eighth leading
cause of mortality in the United States, resulting in approximately 44,000
preventable deaths annually. Nearly one in five Americans reports hav-
ing experienced medical errors of some kind affecting them or their fam-
ily members. These rising numbers show that medical errors are a growing
epidemic in the United States.
With this book, we aim to draw the attention of the readers on some of
the common medical errors and patient safety/quality improvement issues
faced in the healthcare system today through clinically relevant, vignette-
based descriptions of patient safety issues. The vignettes are derived from
the editor’s (Raghav Govindarajan’s) own experience as a clinician, educator,
and administrator.
Each chapter highlights a particular aspect of patient safety in a nonpunitive,
non-accusatory tone along with a brief review of pertinent literature. The spec-
trum of medical errors discussed in this book includes system-based errors,
diagnostic errors, errors due to communication failure, and physician-related
errors. Further, each chapter provides a comprehensive, clinically relevant
review of literature with easy-to-understand tables, flowcharts, and figures.
This book also serves as an outline for medical schools, nursing schools,
medical residencies, and any other educational courses to develop their own
patient safety and quality improvement curriculum.
While the book is written with the intention of educating healthcare pro-
viders and any personnel who are involved in patient care either directly or
indirectly (of all stages and at all levels), the clinical vignettes and material
discussed in the book will be a great read even for the general audience and
will provide an insight into some of the pressing issues affecting our health-
care system today.
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