Kaveh G. Shojania, MD; Kathlyn E. Fletcher, MD, MA; Sanjay Saint, MD, MPH
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, firstname.lastname@example.org.
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.
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.
Table. Categories of Contributing Causes to the Adverse Outcome in This Case*
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Stephen R Workman
October 26, 2006
Pancreatitis in an 88 year old patient should never be considered mild
"The initial management of the patient reflects the treating clinician's understandable expectation of a rapid recovery from "mild pancreatitis."
This apparently understandable expectation is wrong. Pancreatitis in patients over 65 years of age would have a statistical mortality of 20%. (1) In patients over eighty the mortality rate is likely higher, perhaps 40%. (2) Usual prognostic criteria do not appear to apply to elderly patients. (2,3) Nor does resolution of pancreatitis, as occurred in this case, guarantee a good outcome: age adjusted mortality rates are 30 times higher in the first month after admission and seven times higher in the second. (1)
Failure to appreciate that even 'mild' disease in this particular patient had a very high mortality rate was likely the single biggest contributor to a potentially preventable death. Admission to an acute care unit to help ensure closer monitoring and adherence to therapy was likely the fundamental oversight.
1.Goldacre MJ, Roberts SE.BMJ. 2004 Jun 19;328(7454):1466-9.
2Paajanen H, Jaakkola M, Oksanen H, Nordback I. Eur J Surg. 1996 Jun;162(6):471-5.
3 Fan ST, Choi TK, Lai CS, Wong J. Br J Surg. 1988 May;75(5):463-6
Paul F. Griner
University of Rochester School of Medicine
More on GME and Patient Safety
In their Quality Grand Rounds article, Graduate Medical Education and Patient Safety: A Busy-and Occasionally Hazardous-Intersection (1), Shojania and colleagues described a case where problems in communication and supervision among and between residents and an attending physician let to the possible preventable death of an 88 year old woman with intestinal obstruction. The authors suggested how one might minimize sign-out and handoff problems, reduce tension between service and supervision, and encourage trainees to call for help.
The case description noted that a fourth year medical student offered to insert a nasogastric tube because she wanted to learn how to perform the procedure. Miscommunication between the student and supervising nurse resulted in the insertion of a feeding tube instead, just one in a sequence of errors that ultimately led to the death of the patient. In their following discussion of this portion of the case description, the authors overlooked an opportunity to comment on approaches to "learning by doing" through the use of simulation. Soon, it will no longer be necessary for medical students to perform their first procedures on patients. Simulation laboratories in medical schools will provide the opportunity for students, trainees, and faculty to achieve core competencies in invasive procedures without risk of harm to patients. Consensus statements have been developed in regard to the use of tools such as simulation and virtual reality for the teaching and evaluation of these competencies (2). How the current and future use of these technologies will replace the apprenticeship model for the development of procedural skills should be of interest to all medical educators (3)
The case also highlighted the importance of knowing when to call for help. In their discussion of this issue, however, the authors failed to suggest strategies to reduce the potential for patient harm when the resident does not call for help. One such strategy is the development of a rapid response system in hospitals where nurses are authorized to call for medical emergency teams when a patient's condition is observed to be unexpectedly and seriously worse. Although this approach was initially developed in non-teaching hospitals, it is equally relevant in teaching hospital settings. Readers may be interested in the recently published findings of the first consensus conference on medical emergency teams (4).
1. Shojania, KG, Fletcher, KE, Saint, S. Graduate Medical Education and Patient Safety: A Busy-and Occasionally Hazardous-Intersection. Ann Intern Med. 2006; 145: 592-98
2. Vozenilek J, Huff JS, ReznekM, Gordon JA. See one, Do one, Teach one: Advanced Technology in Medical Education. Acad Emerg Med. 2004; 11:1149-54
3. Gorman PJ, Meier AH, Rawn C, Krummel TM. The Future of Medical Education is no Longer Blood and Guts, it is Bits and Bytes. Am. J. Surg. 2000; 180: 353-6
4. Devita MA, Bellomo R, Hillman K, et al. Findings of the First Consensus Conference on Medical Emergency Teams. Crit Care Med. 2006; 34:2463-78
University Hospitals of Amiens
October 30, 2006
Roots cause analysis ? May be not always right
Quality of care may and must be improved. However, the recent quality grand round by Shojania may not be the best example to support the roots cause analysis and may increase the cultural gap between the "physicians" and "qualiticians". The defect in care was not identified. Indeed, morphine have been classified as class I drugs-associated with pancreatitis (Trivedi CD, Pitchumoni CS. Drug-induced pancreatitis: an update. J Clin Gastroenterol 2005;39:709-16). Moreover morphine has well known deleterious effect on gut motility and avoiding the use of exogenous opioids is a key factor to reduce postoperative ileus (Kehlet H, Holte K: Review of postoperative ileus. Am J Surg 2001, 182:3S-10S.These two points are based upon old and well documented physiological effects. Moreover alternative to morphine exists. It may be fine to look for physicians who are also communicators, traning models ("balancing supervision and trainee autonomy"), managers, and so on for the same price. Nevertheless, don't forget to teach them physiology and therapeutics.
Kenneth A Hoekstra
Western States Chiropractic College
November 6, 2006
Graduate Medical Education and Patient Safety: Preventing Harm
The article by Shojania et al. addresses patient safety and potential for harm during inadequate supervision of medical trainees and staff (1).
As noted in this article, medical errors may stem from lack of communication between health care workers, lack of follow through (students) or follow up (supervisors) and/or lack of appropriate working conditions (eg. long hours) (1). However, students, residents and medical staff in training programs have much potential to improve the quality of life for patients and thus, may reduce morbidity/mortality in certain cases (2). Furthermore, if senior supervisors demonstrate a commitment to making safety a key component of risk management and assessment then such medical tragedies may well be minimized (3,4).
1.Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. Ann Intern Med. 2006 Oct 17;145(8):592-8.
2. Seiden SC, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care. 2006 Aug;15(4):272-6.
3. Runy LA. 25 things you can do to save lives now. Hosp Health Netw. 2005 Apr;79(4):40-4, 46-8, 2.
4. Weinstock M. Save lives now. Patient care. Transitioning care.Hosp Health Netw. 2005 Jun;79(6):27-8, 4.
Matthew N. Fine
November 10, 2006
To the Editor:
I read with interest the excellent Quality Grand Rounds: Improving Patient Care regarding graduate medical education. (1) Even though we are a small (100 bed) community-based semi-rural, non-teaching hospital, I was struck by the similarity to a recent Root Cause Analysis performed here. These similarities include: 1) an unreported, unlooked for imaging study; 2) "anchoring bias"; (2) 3) lack of a structured sign-out system; 4) lack of communication between admitting and covering physician; and 5) time and workload pressures.
I was also struck by the appearance that the nursing involvement in the care was not considered in the analysis of this case. There was no indication that the nurse was aware of why she was asked to insert a nasogastric tube or that this issue was recognized as a contributing cause. If the nurse(s) involved had known the reason for the NG tube, the correct tube and, perhaps, the appropriate type of suction would have been used. At a time when medicine is increasingly systems and protocol driven and nursing care increasingly task oriented, having a team approach which includes the nursing staff has become more important but harder to accomplish.
It has appeared to us that a major barrier to a more collaborative approach is the number of interruptions (3) and workarounds (4,5) that interfere with nurses' work flow. Over a shift these can add up to considerable time. Getting back on task can take additional time and lead to errors. Addressing this issue could allow nurses more time to be involved with the medical staff and be more aware of the medical issues involved. We are working very hard to correct this situation so that nurses can better function as part of the team. Clearly, in this case, if the hole in the nursing staff's slice of the Swiss cheese was smaller the outcome could have been much different.
I would like to thank the authors of this report and editors of this series for putting patient safety on a more equal footing with the more traditional medical specialties. Attention to these issues will not only improve patient care, it will make good care of patients more rewarding and enjoyable for everyone involved. However, we can't make progress unless we believe there are solutions.
Matthew N. Fine, MD
1. Shojania KG, Fletcher KE, Saint S. Improving Patient Care. Graduate Medical Education and Patient Safety: A Busy and Occasionally Hazardous "“ Intersection. Ann Intern Med. 2006;145: 592-598 .
2. Redelmeier DA. Improving Patient Care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115-20.
3. Brixey JJ, Robinson DJ, Tang MZ, Johnson TR, Zhang J, Turley JP. Interruptions in Workflow for RNs in a Level One Trauma Center. AMIA Symposium Proceedings. 2005;86-90
4. Spear SJ, Schmidhofer M. Improving Patient Care. Ambiguity and Workarounds as Contributors to Medical Error. Ann Intern Med. 2005;142:627 -630.
5. Kobayashi M, Fussell S, Xiao Y, Seagull FJ. Work Coordination, Workflow, and Workarounds in a Medical Context. CHI; 2005:1561-1564.
Frank N. Finkelstein
November 14, 2006
Graduate Medical Education and Patient Safety
As a physician who did not get a good night's sleep from 1973 to 1998, I was both amused and appalled by this article.
It seems that our now well-rested house staff do not communicate with each other and with nursing staff, and it appears that disease does not respect shift changes and weekends! Horrors!
It also seems that a poorly supervised medical student in a university hospital may not be superior to a "Local MD", who at least knows the difference between a feeding tube and a suction tube and is subject to the intense scrutiny of his peers and the patient's family.
Now that we have allegedly done away with the dangerous sleep- deprived (dare I speak the name?) solo practitioner, and are both kinder and gentler to the house-staff, it occurs to me to ask in retrospect whether there is any evidence-based medicine to show that the present system of shift-working multiple caregivers complete with handoffs and lovely weekends on Cape Cod has resulted in a documented improvement in patient outcomes?
The old adage regarding multiple culinary personages spoiling the hot infusion of meat may still hold true.
Kaveh G. Shojania
Ottawa Health Research Institute
December 17, 2006
Authors' Response to letters regarding 'Graduate medical education and patient safety'
We thank Dr. Fine for his kind remarks about the Quality Grand Rounds series. Our article highlighted the importance of clear communication and the ways in which failure to explain key aspects of the care plan contributed to several of the errors in the case. We focused on physician trainees because of space limitations. However, we agree that poor physician-nurse communication contributed to the mistaken insertion of a feeding tube instead of a nasogastric tube, and failings in this area are an important source of medical errors.
We agree with Dr. Griner that the use of simulators promises to improve the acquisition of key procedural skills by trainees. A rapid response team may also have helped in the case, but the physicians' responses to the nurse's pages were in fact quite timely, and the nurse seemed satisfied by their assessments. In other words, even if a rapid response team had been available in the hospital at the time, there was no indication that the nurse would have called for it. Moreover, despite widespread enthusiasm for rapid response teams, the only randomized controlled trial to evaluate their efficacy showed no benefit,(1) and other studies that have reported benefits suffer from important methodological limitations.(2)
Dr. Workman highlights our characterization of the treating clinicians' impression of "mild pancreatitis" and their expectation of an uneventful recovery. As part of our preparation of the case discussion, we reviewed the study cited by Dr. Workman, which reported outcomes of pancreatitis stratified by age.(3) While it is not clear what proportion of patients who died initially appeared clinically stable (as in the case we discussed), we agree that the possibility of adverse outcomes from pancreatitis should never be underestimated, especially in the elderly.
1. Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365:2091-7.
2. Winters BD, Pham J, Pronovost PJ. Rapid response teams--walk, don't run. JAMA. 2006;296:1645-7.
3. Goldacre MJ, Roberts SE. Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality. BMJ. 2004;328:1466-9.
Munir E Nassar
May 1, 2007
Supervision of medical students, and interns
I would like to commend Dr Shojania and colleagues(1) on their awareness article dealing with patient safety in graduate medical education, and also Dr. Griner's excellent remedy for non bedside procedures teaching.
In the old days teaching and supervising medical students and interns during bedside procedures was a very important part of teaching the medical students and interns/surgical/pediatric/EENT/and ob-Gyn by residents on duty to make sure that bedside procedures are done safely, properly, ethically and efficiently with minimum discomfort to patients after obtaining proper consent. The preparation to undergo a medical bedside procedure had to involve a registered nurse and to be present during the procedure. If the procedure, after he/she had watched its performance previously, and learning by observation, proved difficult for the student or the intern then the resident immediately took over and he could call his superior to help out if necessary Such a hierarchy in graduate medical education was basic and superior to a non pyramid system of residents and interns which is prevelant today, because it is a better way for teaching purposes. In my opinion even after practicing on simulated human like models, actual supervised procedures are the best insurance.
Reference : (1) Shojania KG, and colleagues. Ann Int Med 2006; 145:592-598
Shojania KG, Fletcher KE, Saint S. Graduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection. Ann Intern Med. ;145:592–598. doi: 10.7326/0003-4819-145-8-200610170-00008
Download citation file:
Published: Ann Intern Med. 2006;145(8):592-598.
Education and Training, Gastroenterology/Hepatology, Hospital Medicine.
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use