Quality Grand Rounds: The Case for Patient Safety

In this issue, we present the 13th and final article in the Quality Grand Rounds series, the case of an elderly woman admitted to a teaching hospital early in the academic year with a mild episode of acute pancreatitis (1). Despite initial improvement, her condition deteriorated over the course of several days; her ultimate death was attributable to delayed diagnosis and management of a small-bowel obstruction. The case highlights problems in resident supervision, fumbled handoffs, adverse consequences of housestaff duty-hour limitations, and deficient safety systems. As with many cases of medical errors, the explanation is messy and multifaceted, resisting a clean, simple fix.

The case stands as a fitting bookend to the entire Quality Grand Rounds series. Our first case, “The Wrong Patient,” described a woman who received an invasive electrophysiology procedure intended for a patient with a similar last name (2). In their discussion of that case, Chassin and Becher identified 17 individual mistakes, none remarkable or difficult to understand in isolation. Together, they provided the necessary ingredients for a breathtaking error.

In between, we have published 11 other cases that illustrate the breadth of the patient safety field (3–13). Some cases—a patient dies after a nurse mistakenly flushes an intravenous line with insulin instead of heparin, another dies of an air embolism after incorrect removal of a central catheter—beg for such “systems fixes” as computerized physician order entry, bar coding, checklists, readbacks, and competency-based credentialing (3, 10). Other cases—a patient's “hospitalization from hell,” for example (6)—demonstrate that safe systems need to be accompanied by an institutional culture that prizes safety and …