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Quality Grand Rounds: The Case for Patient Safety

Robert M. Wachter, MD; Kaveh G. Shojania, MD; Amy J. Markowitz, JD; Mark Smith, MD, MBA; and Sanjay Saint, MD, MPH
[+] Article, Author, and Disclosure Information

From University of California, San Francisco, San Francisco, California; University of Ottawa and Ottawa Health Research Institute, Ottawa, Ontario, Canada; California HealthCare Foundation, Oakland, California; and Ann Arbor VA Medical Center and University of Michigan Medical School, Ann Arbor, Michigan.

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, bobw@medicine.ucsf.edu.

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.

Ann Intern Med. 2006;145(8):629-630. doi:10.7326/0003-4819-145-8-200610170-00013
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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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Quality Grand Rounds
Posted on October 20, 2006
Alain Braillon
University Hospitals of Amiens
Conflict of Interest: None Declared

"This issue contains the final article in the Randomized Controlled Trials series". This is not fiction, only the near future. The first step is the inacceptable RIP for Quality Grand Rounds (QGR). This section is not only useful for it specific content, it encourages and helps to develop QGR. Indeed, QGC may be the commun law in the US, elsewhere is it is quite different. In each issue I was craving for the article in the QGR series. Now I feel despaired. Is a doctor somewhere who can reanimate the QGR series ?

Conflict of Interest:

None declared

Quality and Grand Rounds
Posted on October 26, 2006
Helen Feit
No Affiliation
Conflict of Interest: None Declared

To the Editor: Shojania and colleagues discuss the intersection of graduate medical education and patient safety in the final article of the Quality Grand Rounds series. Although multiple problems in academic centers are highlighted, the bottom line is that an 88 year old woman died because a nurse thought a feeding tube was requested instead of a nasogastric tube, and because subsequently a nurse inadvertently attached the feeding tube to a nozzle for tracheal aspiration. I do not believe, therefore, that the main issue was communication. Surely, an order was written for a nasogastric tube. And hooking the tube up incorrectly is a nursing quality issue. The article fails to address the core issues in the case.

Conflict of Interest:

None declared

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