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Patient Safety

Description: Patient safety rounds at VA or Jacksonville.

Attend a VA patient safety rounds which occur on Thursdays beginning at 1:00.  Please contact Julie Whitney at 376-1611 ext. 6641 or  Observe how an interprofessional team of nurses, industrial hygienists, environmental safety specialists, patient safety, and environmental care staff inspect the medical center environment to ensure that proper housekeeping, sanitation, and maintenance are being performed and areas are free of physical hazards; insure adherence to infection control standards; evaluate patients at risk for preventable adverse events. Students are also invited to attend the Medication Safety Committee meeting held Mondays at 11:00 a.m. .  Please contact Julie Whitney at if you are interested in attending this meeting.

Attend a Jacksonville “Rapid Response Patient Rounds”. If you are interested in attending, contact Cynthia Gerdik at

Submission instructions: Summarize what you learned and reflect on ways this may or may not change your practice in 1-2 paragraphs.

Evaluation criteria: All submissions in this category that following the directions will meet the portfolio quality/safety requirement.

Description: Identify an adverse event or near miss that occurred during the rotation. This is not an indictment on anyone so please do not use names and make every effort to protect privacy. Perform a root cause analysis of the problem by clearly stating 1. what happened, 2. why it happened, and 3. what can be done to prevent it from happening again. When addressing why it happened, you will usually need to identify others involved in the chain of events and ask them “why?”. Keep asking “why?” at every stage of your probing until you get to the point you think you have identified the root cause. Only then will you be able to propose a solution to prevent it happening again.

Submission instruction: The following is a suggested format for writing up the incident and it should take no more than a page. Alternatively, 3-4 students in your group would like to discuss, rather than write-up the event, I am happy to arrange a time for a small group discussion that would still follow the same general format below.

1. What: Briefly describe the event.

2. Why: Identify the root potential cause(s) of the adverse event.

3. Prevention: Suggest possible solutions.

Evaluation criteria: All submissions in this category that following the directions will meet the portfolio quality/safety requirement.


“To Err is Human”, report from the Institute of Medicine

This is a brief summary of the seminal report that drew the public’s attention to the issue of medical errors and consequently has driven the medical community to take more aggressive action to address this problem.

VA National Center for Patient Safety

This site gives a brief overview of root cause analysis.

Wachter RM, Shojania KG, et al. Learning from our mistakes: quality grand rounds, a new case-based series on medical errors and patient safety. Ann Int Med. 2002;136:850-2

This editorial introduces the series “Quality Grand Rounds” in the Annals of Internal Medicine. The following is a list of the articles in that series along with the website for the abstract:

1. Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwanted Suffering. Lynn J, Goldstein NE. Ann Int Med 2003;138:812-8.

2. A hospitalization from Hell: A Patient’s Perspective on Quality. Cleary PD. Ann Int Med 2003; 138:33-9.

3. Hospital-Onset Infections: A Patient Safety Issue. Gerberding JL. Ann Int Med 2002; 137:665-70.

4. Unexpected Hypoglycemia in a Critically Ill Patient. Bates DW. Ann Int Med 2002; 137:110-6.

5. Are Bad Outcomes from Questionable Clinical Decisions Preventable Medical Errors? A Case of Cascade Iatrogensis. Hofer TP, Hayward RA. Ann Int Med 2002; 137:327-33.

6. The Wrong Patient. Chassin MR, Becher EC. Ann Int Med 2002; 136:826-33.

Volpp KGM, Grande D. Residents’ Suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003; 348(9): 851-5.

Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003; 348(25): 2526-4.

Gandhi TK, Weingart SN, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003; 348(16): 1556-64.

Complications: A Surgeon’s Notes on an Imperfect Science, Atul Gawande, M.D. 2003, Picador, 288 pages.

This is an excellent, highly readable book written by Dr. Gawande when he was a surgical resident. He addresses many types of errors through the use of compelling stories. This was a NY Times notable book.