Improving Patient Safety

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

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• Sistemas e serviços de saude
• Sistema juridico da saúde e Segurança Social
• Gestão da produção e do controlo de qualidade
• Indústrias de serviços
• Médico administração e gestão

JAMA Intern Med;patient safety;Work Home Interaction;patient centered care;Copenhagen Burnout Inventory;medical errors;Van Der Vleuten;system based errors;MEE;culture of patient safety;PDSA;diagnostic error;Diagnostic Errors;Emotional Exhaustion;Patient Safety Culture;Harvard Medical Practice Study;Physician Burnout;Effective RCA;PDSA Cycle;National Academy;Oldenburg Burnout Inventory;Transfer Errors;Graduate Medical Education;Medical Chart Review;Framing Effect;Quality Improvement Projects;Patient Safety Issues;Fishbone Diagram;Defined Core Competencies;Medical Overuse