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Cases & Commentaries
- Spotlight Case
- Web M&M
Lisa M. Bellini, MD; February 2004
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.
Perspectives on Safety > Interview
Patient Safety in Emergency Medicine, June 2010
Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.
Journal Article > Study
Stahel PF, Flierl MA, Smith WR, et al. Am J Med Qual. 2010;25:398-401.
An orthopedic surgery department implemented a confidential, real-time system for reporting intraoperative adverse events and analyzed these events in structured morbidity and mortality conferences. Although physicians felt this process improved patient care, it resulted in a significant increase in reported error rates, which, as the authors point out, could have resulted in lower quality ratings for the department.