Improving Patient Safety

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.  

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 Patients our Lives?

HARLEEN KAUR

6 Tools and Strategies for Quality Improvement and Patient Safety: A Primer for Healthcare Providers

ANUDEEP YELAM AND RAGHAV GOVINDARAJAN

Index