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In November 1999, the Institute of Medicine (IOM) issued the report To Err is Human, detailing a problem of preventable medical errors that were killing as many as 98,000 inpatients per year. Subsequent publications have estimated it may be as high as 400,000 per year. Specific types of medical errors highlighted in the IOM report include error in the administration of treatment, failure to order and follow-up on indicated diagnostic exams, and avoidable delays in care and treatment. Many years later problems still exist: nearly 2 million patients a year develop infections during their hospitalizations, and 90,000 to 100,000 of those infected die, while hand-hygiene rates range from 30% to 70% at most acute care facilities. The IOM report also estimated that medical errors cost the US $17 billion to $29 billion a year, and called for sweeping changes to the health care system to improve patient safety.

Improvements in patient safety have focused on addressing the root causes of these preventable patient harm events, specifically events related to poor communication, lack of teamwork, fragmentation of care, and a lack of leadership from the medical community. In addition, patient safety experts have also implored physicians and hospitals to approach patient harm events with transparent, open, and honest communication between caregivers and patients and families in order to learn from mistakes and poorly designed systems.

This chapter reviews ways in which hospitalists may actively participate in the prevention of patient harm and provide appropriate management and assistance when patient harm does occur.


Most patient safety experts would agree that the areas of highest priority to proactively maximize patient safety fit into three broad domains: communication, teamwork, and leadership. Within each of these domains lie critical concepts and issues about which the highly reliable and safe-practicing physician must remain mindful.

TABLE 20-1Preventing Patient Safety Events


No chapter on the prevention of patient harm is complete without a major focus on the role communication—or lack thereof—plays in serious patient safety events. The most common types of communication of high priority in patient safety are listed in Table 20-1.


Year after year The Joint Commission (TJC) publishes data showing 65% to 70% of all sentinel events are rooted in communication breakdowns. It appears that since the implementation of the Accreditation Council for Graduate Medical Education resident physician work hour limitations the communication problems have increased, especially in the area of handoffs, when the responsibility of care ...

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