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JAMA Performance Improvement: Do No Harm

The JAMA Performance Improvement podcast reviews individual case summaries where the quality of care was suboptimal. Each episode uses a root cause analysis to investigate the case, understand why the complications occurred, and suggest how health care systems might be improved to avoid similar problems in the future.

Latest episode

Medication Errors in Hospitals—It's Everyone's Fault

A patient was admitted to the hospital and got three times their normal dose of phenytoin resulting in phenytoin toxicity and a long hospital stay. Analysis of the error revealed problems with hospital organization, supervision issues and having an environment that facilitates errors. Errors don’t occur simply because one clinician makes a mistake—rather they occur because the hospital system fails to prevent them.
Listen to the episode in the player below.

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More episodes

Retained Foreign Body From a Sheared Off Lumbar Drain

A resident is asked to remove a drain that was placed in the lumbar space during an operation. Having never seen this sort of drain before not having removed one, the resident proceeded to remove the catheter. Several days later, the patient complained of persistent drainage. An 11-cm segment of retained catheter was removed. This JAMA Performance Improvement article discusses how to avoid this sort of problem as well as how to ensure that resident physicians have sufficient skills to perform procedures on their own. We talk with Drs Cynthia Barnhard, John DeLancey, authors of Retained Lumbar Catheter Tip, and Dr Aaron Reynolds and Dr David Baker.
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Managing Patients With a Latex Allergy

A patient has a known history of latex allergy and goes to the operating room to have an operation. The operating room does not have latex-free urinary catheters, but because latex allergies are seldom serious, a latex-containing catheter is placed. The patient went into anaphylactic shock, requiring the procedure to be aborted. The root cause analysis revealed communication issues regarding the allergy history and the need to ensure that latex-free supplies are available throughout the hospital.
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Ensuring Staff Safety Against Violent Patients

A recently imprisoned patient with psychosis was admitted to a psychiatric hospital. He unexpectedly became violent and assaulted a staff member, causing permanent serious injuries. The root cause analysis identified various staffing patterns to minimize the risk of injury from violence, and suggested employing a milieu officer who is specifically trained to manage potentially violent psychotic patients.
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Performing the Wrong Procedure

A patient is sent to a procedure area to have a central line placed, and due to a series of communication errors, has the wrong catheter placed – one that could have caused serious harm. The root cause analysis identified a series of communication problems regarding informed consent and taking off of orders. The risk for this error occurring again was minimized by the implementation of a “ticket to ride” handoff tool.
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