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Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Journal Article > Commentary
Buerhaus PI. Health Affairs. 2007;26:w687-w696.
Lucian Leape, MD, is generally known as the father of the modern patient safety movement in the United States. This engaging interview with Dr. Leape shares his thoughts on the current state of patient safety and how the health care system is responding. He reflects on the success of the 100,000 Lives Campaign, Michigan's efforts to eliminate central line infections, the development of trigger tools to identify adverse events, and increased attention to error disclosure. On the other hand, he also discusses the need for greater teamwork training, more effective hospital leadership, and improved quality and safety curricula. An AHRQ WebM&M conversation with Dr. Leape also discusses his remarkable career and his thoughts on the patient safety movement.