Medical Journal Series Examines Medical Errors in Eight-Part Case Study Series
The June 4 issue of the Annals of Internal Medicine features the first in a series of articles the journal plans to run examining medical errors at hospitals, the San Francisco Chronicle reports. Created by Dr. Robert Wachter, an expert on patient safety and health care quality at the University of California-San Francisco Medical Center, where he serves as chief of medical services, the "Quality Grand Rounds" series seeks to "change the culture of medicine" by providing a "frank discussion" of mistakes. "A patient can be confident that it's extremely unlikely that [a mistake] will happen, but it happens too often, and we're not going to fix it unless we can become more open about talking about it," Wachter said (Hall, San Francisco Chronicle, 6/18). Wachter and colleague Dr. Kaveh Shojania asked doctors across the nation to discuss their mistakes, promising that no names would be revealed. The case studies were then analyzed and written up by experts not affiliated with the institutions where the errors occurred. The series begins with an article titled "The Wrong Patient" by Drs. Mark Chassin and Elise Becher of the Manhattan-based Mount Sinai School of Medicine, in which the authors explore a case of mistaken identity that led to a heart test being performed on an aneurysm patient. Chassin and Becher provide a minute-by-minute account of the case and determine that 17 separate errors, including a series of communication failures, led to the mix up. The errors were largely the result of what the authors call a "culture of low expectations," in which the hospital staff had become accustomed to poor communication, a lack of teamwork, "sloppy" record keeping and a "patchwork" of computer systems that were not adequately integrated. Since the error occurred, the hospital has instituted a system to ensure that employees verify a patient's identity before performing any procedure. The medical error series will continue in the journal over the next year (Grady, New York Times, 6/18).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.