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