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SPOTLIGHT ON RESOURCES
Over the last two weeks, the
whole country has followed the fate of Jesica Santillan, the teenager
who died after receiving a transplant of the wrong blood type at Duke
University Hospital. Not all medical errors take such a tragic turn, but
errors and lapses in patient safety occur at alarming rates, according
to a well-publicized 2000 IOM report. This month’s spotlight turns to a new online journal from AHRQ that uses actual cases of medical error submitted by readers to teach health care providers how to spot and avoid errors. The journal, dubbed Morbidity and Mortality Rounds on the Web, features expert analysis of each case, learning modules that can be used for continuing medical education credit and discussion forums. The site will post error case studies in five different specialties, from psychiatry to pediatrics. Submissions are posted anonymously, although selected contributors do receive an honorarium. The current cases range from the bizarre (a flying infusion pump drawn to an MRI magnet) to the routine (two "Mr. Smiths" on the same hospital floor almost receive each other's medication). Each month, one of the cases will serve as a "Spotlight Case" for expanded training, including quizzes, readers' polls and other multimedia teaching tools. Power Point presentations of these Spotlight Cases are available for free download. You can submit a case or just browse the new journal at http://www.webmm.ahrq.gov/default.aspx.
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