Patient safety lapses in the hospital

Earlier this month, at the third annual American Medical Student Association Patient Safety and Quality Leadership Institute, I listened with sympathy — and, frankly, a certain amount of discomfort — to a fourth-year medical student’s account of his grandmother’s recent hospitalization at a well regarded inpatient facility in New York City.

Admitted with an initial diagnosis of pneumonia, Cole Zanetti’s grandmother languished in the hospital for almost four weeks.

As the medically savvy member of the family, Cole, a student at Texas College of Osteopathic Medicine, had taken on responsibility for being at the hospital to receive updates on his grandmother’s condition.

But what should have been a simple task became an exercise in frustration as each doctor who entered the room offered little information.

And each said something different.

After weeks in the hospital, one doctor told Cole that his grandmother’s liver was failing; another said her breathing continued to be the biggest problem; and still another said that she was stable and ready for discharge.

Adding to Cole’s concern, his grandmother was transferred to different rooms on four separate occasions.

Lack of adequate communication during these transitions led to a delay in changing the patient’s IV and failure to administer a medication for three days.

Most distressing to Cole and his family were what appeared to be lapses in routine safety procedures — leaving the alert button out of the patient’s reach when moving her to a chair, for instance.

Cole believes that medical students have a moral imperative to take action by advocating for a medical education system that integrates patient safety and system improvement. His observations and questions resonated with both the medical student attendees and the Institute faculty:

“As medical students we are observers of various healthcare systems. We go from one hospital to the next, staying only long enough to understand it and then moving on. We see some processes that work well, and some that are appallingly ineffective.

“How can medical students and healthcare professionals stand by watching as our patients are subjected to such inadequate systems?

“We need to go back to our medical school and help create opportunities for others to understand the impact of our failed system … and our responsibility for due diligence.

“We need to change our archaic customs and move forward acknowledging our patients’ need for healthcare delivery redesign.”

As a physician at an academic medical center, I am ashamed to admit that this student’s perceptions are all too accurate.

Unfortunately, his experiences as a doctor in training and as a patient’s family member are not out of the ordinary. Similar scenarios play out in hospitals across the country every day.

The good news is that there are proactive efforts already under way in medical education to change things.

Chief among these is the American Association of Medical Colleges’ (AAMC) “Integrating Quality (IQ),” an organizational quality improvement initiative aimed at integrating quality and patient safety improvement into the educational process across the full continuum of medical education.

Currently, the leaders of this initiative are engaged on three major fronts:

  • Sharing innovative approaches to quality and safety integration
  • Packaging resources (e.g., team training initiatives) and responding to the needs of AAMC members
  • Assisting AAMC members in implementing educational and clinical quality and safety initiatives

As the Institute faculty presented information about IQ and other initiatives — such as understanding breakdowns in healthcare delivery systems, incorporating patient safety into medical education curricula — Cole and the other medical student attendees were energized.

Shortly after the Institute ended, Cole wrote:

“It was an overwhelmingly therapeutic experience for me to learn that an enormous push for change is already under way.

“I have taken action to make a change in my medical school’s curriculum … and talked with key coordinators for educational development.

“I am looking at two residency programs with a strong culture of patient safety and quality, and I fully intend to make this my career.”

For me, there could not have been a more uplifting end to the story!

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Originally published in MedPage Today. Visit for more health policy news.

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