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17 October 2006 | Volume 145 Issue 8 | Pages 592-598
A patient admitted to a teaching hospital with a mild episode of acute pancreatitis initially improved, but then her condition deteriorated and she subsequently died. The initial deterioration probably reflected bowel obstruction, as shown on an abdominal radiograph that an on-call intern forgot to review. This diagnostic delay was compounded by poor communication that resulted in a medical student inserting a feeding tube—rather than a nasogastric tube—to decompress the bowel, followed by failure to recognize how ill the patient had become. The case highlights the hazards of patient handoffs as well as the importance of clear communication techniques and knowing when to ask for help. The discussion also shows the vicious circle that results when attending physicians fail to provide effective supervision: Not only is safety compromised but trainees lose the experience of being supervised. Consequently, trainees have no models of effective supervision on which to draw when they become supervisors. They then fall into the same trap as those who taught them, busying themselves with direct patient care and providing supervision only as time allows.
Author and Article Information
From Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Clement J. Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin; and Ann Arbor VA Health Services Research and Development Center of Excellence and University of Michigan Medical School, Ann Arbor, Michigan.
Grant Support: Dr. Shojania holds a Canada Research Chair in Patient Safety and Quality Improvement. Dr. Saint is supported by an Advanced Career Development Award from the Health Services Research & Development Program of the Department of Veterans Affairs and by a grant from the National Institutes of Health (DK67451).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Kaveh G. Shojania, MD, The Ottawa Hospital—Civic Campus, 1053 Carling Avenue, Room C403, Box 693, Ottawa, Ontario K1Y 4E9, Canada; e-mail, kshojania{at}ohri.ca.
Current Author Addresses: Dr. Shojania: Ottawa Health Research Institute, The Ottawa Hospital–Civic Campus, 1053 Carling Avenue, Room C403, Box 693, Ottawa K1Y 4E9, Ontario, Canada. Dr. Fletcher: Clement J. Zablocki VA Medical Center and Medical College of Wisconsin, 5000 West National Avenue, Milwaukee, WI 53295. Dr. Saint: 300 North Ingalls Building, Room 7E08, Campus Box 0429, Ann Arbor, MI 48109-0429. IMPROVING PATIENT CARE
QUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.
Graduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection
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