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Errors in Clinical Care - Revised 12-26-06
Errors in Clinical Care - Revised 12-26-06
Errors in Clinical Care - Revised 12-26-06
Overview
Introduction
Case examples
Curriculum
Discussion questions
Resources
Definition1
Possibilities
Resident MD
Supervisory MD
Post Hoc peer review
RNs or other HCWs
Jury
Case Example #1
Case Example #2
Case Example #3
Ethical Agreement
Ethical Agreement
Ethical Agreement
Misdiagnosis
Errors in performance
Drug treatment
Ethical Agreement
An average emergency
physician makes thousands of
decisions every 8-hr clinical shift
Ethical Agreement
Culture of medicine
Ethical Agreement
Time constraints
Staff factors
Understaffing
Threat of litigation
Incident reports
Autopsy
Litigation system
Medication errors
Barcode technology
Computerized Enhancements:6
Radiology discrepancies7,8
Radiology discrepancies
Guidelines/order sets/template
reminders
Clinical practice
Simulation
Simulation (continued)
Supervision
Team-based care
Wellness of caregivers
ED chart reviews
Self-reports
Staff and patient surveys
Resident education
Faculty address and modeling
behavior
Computerized automation for review
Discussion Questions
80 yo woman with history of dementia falls at a nursing home
and sustains a displaced distal radius fracture. Paramedics
administer morphine sulfate en route. On arrival to ED,
additional morphine and midazolam for reduction in the ED.
Post procedure, the patient has a respiratory arrest requiring
intubation. Subsequent chart review reveals an allergy to
morphine.
Discussion Questions
40 yo man without medical history presents with chest
pressure. His ECG shows nonspecific T wave abnormalities
and his discomfort is relieved by a GI cocktail. His troponin
is normal. He is discharged with a diagnosis of
gastroesophageal reflux disease (GERD). He returns to the ED
6 hours later with an ST-segment elevation myocardial
infarction.
Discussion Questions
45 yo man sustains 60% total body surface area burn. He is
intubated and a subclavian central line is inserted, without
CXR confirmation. Over the next few hours, he becomes
hypotensive, difficult to ventilate and hypoxic. The intern
attributes decreased pulmonary compliance to the mans
burns. IV fluids and vasopressors are administered.
The q AM CXR, ordered for ICU rounds, reveals a large
tension pneumothorax.
Resources
1.
Kohn LT, Corrigan JM, Donaldson MS (ed.), To err is human: building a safer
health system. Committee on Quality of Health Care in America, Institute of
Medicine, National Academy of Sciences, 2000.
2.
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG,
Newhouse JP, Weiler PC, Hiatt HH, Incidence of adverse events and
negligence in hospitalized patients. Results of the Harvard Medical Practice
Study. NEJM, 324(6):370-6, 1991.
3.
Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert
L, Newhouse JP, Weiler PC, Hiatt H, The nature of adverse events in
hospitalized patients. Results of the Harvard Medical Practice Study II.
NEJM, 324(6):377-84, 1991.
4.
Croskerry P, Wears RL, Binder LS, Setting the educational agenda and
curriculum for error prevention in emergency medicine. Acad Emerg Med,
7(11):1194-1200, 2000.
5.
Resources
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