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JAMA Performance Improvement: Do No Harm—Taking complications head on to improve the quality of medical care

From the JAMA Network, this is JAMA Performance Improvement: Do No Harm, the podcast about performance improvement and medicine that aims to elevate the quality of care, one patient at a time, with host Ed Livingston, MD.
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JAMA Performance Improvement: Do No Harm—Taking complications head on to improve the quality of medical care
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Jun 20, 2017

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.

Related article: Phenytoin Toxicity—A Significant Adverse Drug Event

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