A new journal series, "Quality Grand Rounds," will harness the power of individual case presentations to educate health care providers about medical errors. The first article in a series of eight appears in the June 4, 2002 issue of the Annals of Internal Medicine. Click here to go to the Annals website.
"The 1999 Institute of Medicine (IOM) report, 'To Err is Human,' shocked people and catalyzed a new focus on patient safety. As our understanding of patient safety and error reduction has matured, we recognized the untapped power and drama of the individual case presentation," said Robert Wachter, MD, associate chairman of the UCSF department of medicine and executive editor of the new series.
In the first article, "The Wrong Patient," two patient safety experts from The Mount Sinai School of Medicine in New York describe the 17 errors that allowed one patient to receive an invasive procedure intended for another patient at an unidentified institution. This, along with all other cases, is based on real experiences and includes analyses from the top experts in the field. Cases do not originate from the experts' home institutions, nor do they identify hospitals or physicians, according to the editors.
"The incident reviewed in the first article raises disturbing questions about the adequacy of patient safety systems in hospitals," said Mark Chassin, MD, chairman of health policy at Mount Sinai School of Medicine and lead author of "The Wrong Patient." "Industries such as aerospace have invested enormous resources to develop systems that minimize such breakdowns. By adapting these systems to health care, we believe that we can do a much better job protecting patients."
How can patients protect themselves? Chassin comments, "Don't hesitate to ask questions of your caregivers about medications, procedures and details of your care. Ideally, a patient in a hospital should have someone with them to serve as advocate and an additional set of eyes."
"In California and other states, a growing body of on-line information about hospitals, will ultimately create a strong market incentive for hospitals to improve," said Mark Smith, MD, CEO of the California HealthCare Foundation and co-executive editor of the new series.