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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. 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%–70% at most acute care facilities. The IOM report also estimated that medical errors cost the U.S. $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 focuses on the important ways in which hospital-based physicians can actively participate in the prevention of patient harm and provide appropriate management and assistance when patient harm does occur.

While there are many important ways that hospital-based physicians can proactively maximize the safety of their patients, most patient safety experts would agree that the areas of highest priority can fit into three broad domains: communication, teamwork, and leadership (see Table 35-1). Within each of these domains lies critical concepts and issues about which the highly reliable and safe-practicing physician must remain mindful.

Table 35-1 Preventing Patient Safety Events
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Practice Point
  • While there are many important ways that hospital-based physicians can proactively maximize the safety of their patients, most patient safety experts would agree that the areas of highest priority can fit into 3 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.

Communication

No chapter on patient safety and 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 ...

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