Robert M. Wachter, MD; Kaveh G. Shojania, MD; Amy J. Markowitz, JD; Mark Smith, MD, MBA; Sanjay Saint, MD, MPH
Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation. The authors are supported by general institutional funds.
Potential Financial Conflicts of Interest: Dr. Wachter is on the Board of Directors of the American Board of Internal Medicine and the Scientific Advisory Boards of Hoana Medical, Codigy, and Intellidot. He has received grants from the Agency for Healthcare Research and Quality. Drs. Wachter and Shojania coauthored the book cited in reference 22.
Requests for Single Reprints: Robert M. Wachter, MD, University of California, San Francisco, Box 0120, 505 Parnassus, San Francisco, CA 94143-0120; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Wachter: University of California, San Francisco, Box 0120, 505 Parnassus, San Francisco, CA 94143-0120.
Dr. Shojania: Ottawa Health Research Institute, The Ottawa Hospital–Civic Campus, 1053 Carling Avenue, Room C403, Box 693, Ottawa K1Y 4E9, Ontario, Canada.
Ms. Markowitz: 527 30th Street, San Francisco, CA 94131.
Dr. Smith: California HealthCare Foundation, 476 Ninth Street, Oakland, CA 94607.
Dr. Saint: 300 North Ingalls Building, Room 7E08, Campus Box 0429, Ann Arbor, MI 48109-0429.
Wachter RM, Shojania KG, Markowitz AJ, Smith M, Saint S. Quality Grand Rounds: The Case for Patient Safety. Ann Intern Med. 2006;145:629-630. doi: 10.7326/0003-4819-145-8-200610170-00013
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Published: Ann Intern Med. 2006;145(8):629-630.
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.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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