Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. Ann Intern Med 2006 Oct 17;145(8):592-8
Date
10/18/2006Pubmed ID
17043341DOI
10.7326/0003-4819-145-8-200610170-00008Scopus ID
2-s2.0-33750716860 (requires institutional sign-in at Scopus site) 60 CitationsAbstract
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.
Author List
Shojania KG, Fletcher KE, Saint SAuthor
Kathlyn E. Fletcher MD Professor in the Medicine department at Medical College of WisconsinMESH terms used to index this publication - Major topics in bold
Aged, 80 and overCommunication
Education, Medical, Graduate
Female
Hospitals, Teaching
Humans
Internship and Residency
Medical Errors
Patient Care
Patient Care Team
