Patient safety is our job

Mrs Jones was a regular patient in our residency practice who presented with a breast mass. After a failed aspiration attempt, one of our third-year residents appropriately noted the concerning nature of this mass and referred the patient to a surgeon for possible biopsy. A mammogram obtained at the time of referral was highly suspicious for cancer. Two years after presentation, our risk management staff informs us that Mrs Jones is filing a malpractice claim for our failure to diagnose her cancer. It seems the mammogram result was never seen by the surgeon and the patient was lost to follow-up.

Mrs Smith contacts the on-call physician complaining of pharyngitis and has classic symptoms of strep throat. Penicillin is prescribed. One half-hour later, the local pharmacist calls noting that Mrs Smith is allergic to penicillin.

Mr Brown has long-standing, treatment-resistant depression. He is prescribed a recently available SSRI. Three weeks later, his psychiatrist calls and chides, “What were you thinking? This patient is on a MAO-I and could have suffered a serious complication.” In reviewing his chart, you see no mention of the MAO-I and the most recent psychiatric note is from 3 years ago.

Maybe one of these real-life cases resonates with you. Perhaps you have had a similar experience. Or maybe you are thinking, “Not in my practice.” But one small study in family practice suggests that medical errors may occur in up to a quarter of our office visits.¹ While many of these errors do not result in significant harm or a malpractice claim, the Institute of Medicine claims, “patient safety is indistinguishable from the delivery of quality care.”²

To spotlight this important area, we will be publishing a series of cases in our Grand Rounds feature that highlight the importance of patient safety. We hope not only to lay bare common safety concerns but to provide you with practical approaches to preventing errors. Isn’t it time we prioritize improvement efforts on keeping our patients safe?

Mrs Jones was a regular patient in our residency practice who presented with a breast mass. After a failed aspiration attempt, one of our third-year residents appropriately noted the concerning nature of this mass and referred the patient to a surgeon for possible biopsy. A mammogram obtained at the time of referral was highly suspicious for cancer. Two years after presentation, our risk management staff informs us that Mrs Jones is filing a malpractice claim for our failure to diagnose her cancer. It seems the mammogram result was never seen by the surgeon and the patient was lost to follow-up.

Mrs Smith contacts the on-call physician complaining of pharyngitis and has classic symptoms of strep throat. Penicillin is prescribed. One half-hour later, the local pharmacist calls noting that Mrs Smith is allergic to penicillin.

Mr Brown has long-standing, treatment-resistant depression. He is prescribed a recently available SSRI. Three weeks later, his psychiatrist calls and chides, “What were you thinking? This patient is on a MAO-I and could have suffered a serious complication.” In reviewing his chart, you see no mention of the MAO-I and the most recent psychiatric note is from 3 years ago.

Maybe one of these real-life cases resonates with you. Perhaps you have had a similar experience. Or maybe you are thinking, “Not in my practice.” But one small study in family practice suggests that medical errors may occur in up to a quarter of our office visits.¹ While many of these errors do not result in significant harm or a malpractice claim, the Institute of Medicine claims, “patient safety is indistinguishable from the delivery of quality care.”²

To spotlight this important area, we will be publishing a series of cases in our Grand Rounds feature that highlight the importance of patient safety. We hope not only to lay bare common safety concerns but to provide you with practical approaches to preventing errors. Isn’t it time we prioritize improvement efforts on keeping our patients safe?

Mrs Jones was a regular patient in our residency practice who presented with a breast mass. After a failed aspiration attempt, one of our third-year residents appropriately noted the concerning nature of this mass and referred the patient to a surgeon for possible biopsy. A mammogram obtained at the time of referral was highly suspicious for cancer. Two years after presentation, our risk management staff informs us that Mrs Jones is filing a malpractice claim for our failure to diagnose her cancer. It seems the mammogram result was never seen by the surgeon and the patient was lost to follow-up.

Mrs Smith contacts the on-call physician complaining of pharyngitis and has classic symptoms of strep throat. Penicillin is prescribed. One half-hour later, the local pharmacist calls noting that Mrs Smith is allergic to penicillin.

Mr Brown has long-standing, treatment-resistant depression. He is prescribed a recently available SSRI. Three weeks later, his psychiatrist calls and chides, “What were you thinking? This patient is on a MAO-I and could have suffered a serious complication.” In reviewing his chart, you see no mention of the MAO-I and the most recent psychiatric note is from 3 years ago.

Maybe one of these real-life cases resonates with you. Perhaps you have had a similar experience. Or maybe you are thinking, “Not in my practice.” But one small study in family practice suggests that medical errors may occur in up to a quarter of our office visits.¹ While many of these errors do not result in significant harm or a malpractice claim, the Institute of Medicine claims, “patient safety is indistinguishable from the delivery of quality care.”²

To spotlight this important area, we will be publishing a series of cases in our Grand Rounds feature that highlight the importance of patient safety. We hope not only to lay bare common safety concerns but to provide you with practical approaches to preventing errors. Isn’t it time we prioritize improvement efforts on keeping our patients safe?