Vignettes In Patient Safety

Medical errors contribute significantly to morbidity and mortality across our healthcare institutions. Due to the increasing complexity of the modern medical practice, a perfect storm of regulatory, market, social, and technical factors, and other competing priorities, created an environment that is primed for patient safety lapses. The spectrum of contributing variables - ranging from minor errors that subsequently escalate, poor communication, and protocol/process non-compliance (just to name a few) - is extensive and solutions are only recently being described. As such, there is a growing body of research and experiences that can help provide an organized framework - based on best practices and evidence-based medical principles - for healthcare organizations to develop, implement, and embrace. Based on the tremendous interest in the initial three volumes of our Vignettes in Patient Safety series, this fourth volume follows a similar model of outlining a patient safety case based on experiences that many clinicians can relate to, and then discusses various factors that may have contributed to a medical error, complication, and/or poor outcome. Building on a problem-based clinical vignette, each chapter then outlines an evidence-based approach to present any related literature, pertinent evidence, and potential contributing factors and solutions to common patient safety occurrences. By focusing on some of the best practices, structured experiences, and objective approaches to medical error genesis, the authors and editors hopefully can lend some insights into how we can make healthcare encounters for all patients, across all settings, better and safer.

It is clearly recognized that medical errors represent a significant source of preventable healthcare-related morbidity and mortality. Furthermore, evidence shows that such complications are often the result of a series of smaller errors, missed opportunities, poor communication, breakdowns in established guidelines or protocols, or system-based deficiencies. While such events often start with the misadventures of an individual, it is how such events are managed that can determine outcomes and hopefully prevent future adverse events. The goal of Vignettes in Patient Safety is to illustrate and discuss, in a clinically relevant format, examples in which evidence-based approaches to patient care, using established methodologies to develop highly functional multidisciplinary teams, can help foster an institutional culture of patient safety and high-quality care delivery.

Over the past two decades, the healthcare community increasingly recognized the importance and the impact of medical errors on patient safety and clinical outcomes. Medical and surgical errors continue to contribute to unnecessary and potentially preventable morbidity and/or mortality, affecting both ambulatory and hospital settings. The spectrum of contributing variables-ranging from minor errors that subsequently escalate to poor communication to lapses in appropriate protocols and processes (just to name a few)-is extensive, and solutions are only recently being described. As such, there is a growing body of research and experiences that can help provide an organized framework-based upon the best practices and evidence-based medical principles-for hospitals and clinics to foster patient safety culture and to develop institutional patient safety champions. Based upon the tremendous interest in the first volume of our Vignettes in Patient Safety series, this second volume follows a similar vignette-based model. Each chapter outlines a realistic case scenario designed to closely approximate experiences and clinical patterns that medical and surgical practitioners can easily relate to. Vignette presentations are then followed by an evidence-based overview of pertinent patient safety literature, relevant clinical evidence, and the formulation of preventive strategies and potential solutions that may be applicable to each corresponding scenario. Throughout the Vignettes in Patient Safety cycle, emphasis is placed on the identification and remediation of team-based and organizational factors associated with patient safety events. The second volume of the Vignettes in Patient Safety begins with an overview of recent high-impact studies in the area of patient safety. Subsequent chapters discuss a broad range of topics, including retained surgical items, wrong site procedures, disruptive healthcare workers, interhospital transfers, risks of emergency department overcrowding, dangers of inadequate handoff communication, and the association between provider fatigue and medical errors. By outlining some of the current best practices, structured experiences, and evidence-based recommendations, the authors and editors hope to provide our readers with new and significant insights into making healthcare safer for patients around the world.

Over the past decade it has been increasingly recognized that medical errors constitute an important determinant of patient safety, quality of care, and clinical outcomes. Such errors are both directly and indirectly responsible for unnecessary and potentially preventable morbidity and/or mortality across our healthcare institutions. The spectrum of contributing variables or "root causes" - ranging from minor errors that escalate, poor teamwork and/or communication, and lapses in appropriate protocols and processes (just to name a few) - is both extensive and heterogeneous. Moreover, effective solutions are few, and many have only recently been described. As our healthcare systems mature and their focus on patient safety solidifies, a growing body of research and experiences emerges to help provide an organized framework for continuous process improvement. Such a paradigm - based on best practices and evidence-based medical principles- sets the stage for hardwiring "the right things to do" into our institutional patient care matrix. Based on the tremendous interest in the first two volumes of The Vignettes in Patient Safety series, this third volume follows a similar model of case-based learning. Our goal is to share clinically relevant, practical knowledge that approximates experiences that busy practicing clinicians can relate to. Then, by using evidence-based approaches to present contemporary literature and potential contributing factors and solutions to various commonly encountered clinical patient safety scenarios, we hope to give our readers the tools to help prevent similar occurrences in the future. In outlining some of the best practices and structured experiences, and highlighting the scope of the problem, the authors and editors can hopefully lend some insights into how we can make healthcare experiences for our patients safer.

Medical errors contribute significantly to morbidity and mortality across our healthcare institutions. Due to the increasing complexity of the modern medical practice, a perfect storm of regulatory, market, social, and technical factors, and other competing priorities, created an environment that is primed for patient safety lapses. The spectrum of contributing variables - ranging from minor errors that subsequently escalate, poor communication, and protocol/process non-compliance (just to name a few) - is extensive and solutions are only recently being described. As such, there is a growing body of research and experiences that can help provide an organized framework - based on best practices and evidence-based medical principles - for healthcare organizations to develop, implement, and embrace. Based on the tremendous interest in the initial three volumes of our Vignettes in Patient Safety series, this fourth volume follows a similar model of outlining a patient safety case based on experiences that many clinicians can relate to, and then discusses various factors that may have contributed to a medical error, complication, and/or poor outcome. Building on a problem-based clinical vignette, each chapter then outlines an evidence-based approach to present any related literature, pertinent evidence, and potential contributing factors and solutions to common patient safety occurrences. By focusing on some of the best practices, structured experiences, and objective approaches to medical error genesis, the authors and editors hopefully can lend some insights into how we can make healthcare encounters for all patients, across all settings, better and safer.

Over the past decade it has been increasingly recognized that medical errors constitute an important determinant of patient safety, quality of care, and clinical outcomes. Such errors are both directly and indirectly responsible for unnecessary and potentially preventable morbidity and/or mortality across our healthcare institutions. The spectrum of contributing variables or ""root causes"" - ranging from minor errors that escalate, poor teamwork and/or communication, and lapses in appropriate protocols and processes (just to name a few) - is both extensive and heterogeneous. Moreover, effective solutions are few, and many have only recently been described. As our healthcare systems mature and their focus on patient safety solidifies, a growing body of research and experiences emerges to help provide an organized framework for continuous process improvement. Such a paradigm - based on best practices and evidence-based medical principles- sets the stage for hardwiring ""the right things to do"" into our institutional patient care matrix. Based on the tremendous interest in the first two volumes of The Vignettes in Patient Safety series, this third volume follows a similar model of case-based learning. Our goal is to share clinically relevant, practical knowledge that approximates experiences that busy practicing clinicians can relate to. Then, by using evidence-based approaches to present contemporary literature and potential contributing factors and solutions to various commonly encountered clinical patient safety scenarios, we hope to give our readers the tools to help prevent similar occurrences in the future. In outlining some of the best practices and structured experiences, and highlighting the scope of the problem, the authors and editors can hopefully lend some insights into how we can make healthcare experiences for our patients safer.