Authors: Wachter Robert M.; Shojania Kaveh G.

Source: Joint Commission Journal on Quality and Patient Safety, Volume 30, Number 12, December 2004 , pp. 665-670(6)

Publisher: Joint Commission Resources

Abstract:

Background: When patient safety became a subject of policy and research, the question was how to engage clinicians—perhaps they would respond more to case studies of dramatic adverse events than to statistics.

The Chronology: In 2001, we launched a case-based series in the Annals of Medicine which focused on diagnosing what ailed the system rather than the patient. For example, in "The Wrong Patient," 17 discrete errors resulted in a woman's receiving a cardiac electrophysiology procedure intended for another patient with a similar last name. The Web-based Agency for Healthcare Research and Quality (AHRQ) WebM&M was then developed as a forum that was part-reporting system and part-journal. Finally, we then applied this approach to writing a book for a popular audience.

Lessons Learned: We found that clinicians were willing to submit cases, assuming that anonymity was protected. Cases of errors that led to harm were generally more compelling than near misses. As in real life, many cases lacked complete information, but sufficient information was usually available to highlight the key lessons. All three vehicles generated substantial readerships and critical praise, indicating that there is a "market" for case-based education about patient safety.

Conclusion: Presenting de-identified cases of medical mistakes in a variety of public venues is an effective way to educate patients and providers about safety.

Document Type: Research article

Publication date: 2004-12-01

More about this publication?

• Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
  
  Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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