Graduate Medical Education and Patient Safety
Authors: Matthew N. Fine
Journal: Annals of Internal Medicine (2007)

Letters1 May 2007Graduate Medical Education and Patient SafetyMatthew N. Fine, MDMatthew N. Fine, MDFrom Oroville Hospital, Oroville, CA 95966.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-146-9-200705010-00016 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR: I read with interest the excellent Quality Grand Rounds article on graduate medical education by Shojania and colleagues (1). Although I work at a small (100-bed), community-based, semirural, nonteaching hospital, I was struck by the similarity of the case to a recent root-cause analysis performed at my hospital. These similarities include an unreported, unlooked-for imaging study; “anchoring bias” (2); lack of a structured sign-out system; lack of communication between the admitting and covering physicians; and time and workload pressures.I was also struck that the authors' case analysis did not consider the nursing involvement in the care. ...References1. Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy—and occasionally hazardous—intersection. Ann Intern Med. 2006;145:592-8. [PMID: 17043341] LinkGoogle Scholar2. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115-20. [PMID: 15657159] LinkGoogle Scholar3. Brixey JJ, Robinson DJ, Tang Z, Johnson TR, Zhang J, Turley JP. Interruptions in workflow for RNs in a level one trauma center. AMIA Annu Symp Proc. 2005;:86-90. [PMID: 16779007] MedlineGoogle Scholar4. Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142:627-30. [PMID: 15838069] LinkGoogle Scholar5. Kobayashi M, Fussell SR, Xiao Y, Seagull FJ. Proceedings of the CHI 2005 Conference on Human Factors in Computing Systems, Portland, Oregon, 2–7 April 2005. New York: Assoc for Computing Machinery Pr; 2005:1561-64. Google Scholar Author, Article, and Disclosure InformationAffiliations: From Oroville Hospital, Oroville, CA 95966.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoThe Cognitive Psychology of Missed Diagnoses Donald A. Redelmeier Ambiguity and Workarounds as Contributors to Medical Error Steven J. Spear and Mark Schmidhofer Graduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection Kaveh G. Shojania , Kathlyn E. Fletcher , and Sanjay Saint Graduate Medical Education and Patient Safety Paul F. Griner Graduate Medical Education and Patient Safety Stephen R. Workman Graduate Medical Education and Patient Safety Kaveh G. Shojania , Kathlyn E. Fletcher , and Sanjay Saint Metrics 1 May 2007Volume 146, Issue 9Page: 685KeywordsCheesesConflicts of interestGraduate medical educationMedical staffNursesPatientsSafety ePublished: 1 May 2007 Issue Published: 1 May 2007 Copyright & PermissionsCopyright © 2007 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...