Kaveh G. Shojania

Quality improvement strategies for hypertension management: a systematic review.

Background:Care remains suboptimal for many patients with hypertension. Purpose:The purpose of this study was to assess the effectiveness of quality improvement (QI) strategies in lowering blood pressure. Data Sources:MEDLINE, Cochrane databases, and article bibliographies were searched for this study. Study Selection:Trials, controlled before–after studies, and interrupted time series evaluating QI interventions targeting hypertension control and reporting blood pressure outcomes were studied. Data Extraction:Two reviewers abstracted data and classified QI strategies into categories: provider education, provider reminders, facilitated relay of clinical information, patient education, self-management, patient reminders, audit and feedback, team change, or financial incentives were extracted. Data Synthesis:Forty-four articles reporting 57 comparisons underwent quantitative analysis. Patients in the intervention groups experienced median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were 4.5 mm Hg (interquartile range [IQR]: 1.5 to 11.0) and 2.1 mm Hg (IQR: −0.2 to 5.0) greater than observed for control patients. Median increases in the percentage of individuals achieving target goals for SBP and DBP were 16.2% (IQR: 10.3 to 32.2) and 6.0% (IQR: 1.5 to 17.5). Interventions that included team change as a QI strategy were associated with the largest reductions in blood pressure outcomes. All team change studies included assignment of some responsibilities to a health professional other than the patients physician. Limitations:Not all QI strategies have been assessed equally, which limits the power to compare differences in effects between strategies. Conclusion:QI strategies are associated with improved hypertension control. A focus on hypertension by someone in addition to the patients physician was associated with substantial improvement. Future research should examine the contributions of individual QI strategies and their relative costs.

The Vanishing Nonforensic Autopsy

Despite the benefits of autopsies, they are performed after less than 10% of all deaths in the United States. Drs. Kaveh Shojania and Elizabeth Burton discuss the trends in U.S. autopsy rates.

Classifying Laboratory Incident Reports to Identify Problems That Jeopardize Patient Safety

We developed a laboratory incident report classification system that can guide reduction of actual and potential adverse events. The system was applied retrospectively to 129 incident reports occurring during a 16-month period. Incidents were classified by type of adverse event (actual or potential), specific and potential patient impact, nature of laboratory involvement, testing phase, and preventability. Of 129 incidents, 95% were potential adverse events. The most common specific impact was delay in receiving test results (85%). The average potential impact was 2.9 (SD, 1.0; median, 3; scale, 1-5). The laboratory alone was responsible for 60% of the incidents; 21% were due solely to problems outside the laboratorys authority. The laboratory function most frequently implicated in incidents was specimen processing (31%). The preanalytic testing phase was involved in 71% of incidents, the analytic in 18%, and the postanalytic in 11%. The most common preanalytic problem was specimen transportation (16%). The average preventability score was 4.0 (range, 1-5; median, 4; scale, 1-5), and 94 incidents (73%) were preventable (score, 3 or more). Of the 94 preventable incidents, 30% involved cognitive errors, defined as incorrect choices caused by insufficient knowledge, and 73% involved noncognitive errors, defined as inadvertent or unconscious lapses in expected automatic behavior.

Understanding medical error and improving patient safety in the inpatient setting

Improving patient safety incorporates two complementary approaches. The first, inspired by research in cognitive psychology and the lessons of accident investigation in other industries, provides qualitative methods for anticipating errors, documenting critical incidents, and responding to them in a blame-free and structured manner. Using such qualitative methods, physicians can generate meaningful strategies for preventing similar occurrences in the future. Hospital-based physicians have an important role to play in promoting a culture of safety by championing incident-reporting initiatives and participating in multidisciplinary teams that analyze adverse events and promote change. The second approach involves applying the results of quantitative clinical research to reduce some of the common hazards of hospitalization. Hospitalists also have an important role to play in this arena because many of these safety targets and the associated clinical practices (e.g., early enteral nutritional support and fall prevention) are not on the radar screens of many hospital-based specialists. In both circumstances, physician participation in collaboration with nurses, pharmacists, nutritionists, and other health care professionals would likely produce important improvements in patient care. More important, physician involvement in these initiatives will undoubtedly contribute visible leadership in promoting a culture of patient safety in hospitals and in health care.

Adverse events detected by clinical surveillance on an obstetric service.

OBJECTIVE: Adverse events are adverse patient outcomes resulting from medical care. We performed this study to estimate the rate of adverse events and potential adverse events—errors that have a high likelihood of causing patient harm—occurring during obstetric care. METHODS: This was a prospective cohort study of an obstetric unit in a teaching hospital. We included patients admitted consecutively to the hospital. A trained observer monitored patients for 72 triggers, which were predefined occurrences deemed likely to indicate an actual or potential adverse event. When a trigger occurred, the observer captured information describing it. A five-person multidisciplinary team, including the observer, three physicians, and a hospital risk manager, judged whether the trigger represented an adverse event or potential adverse event. Adverse events were further characterized as preventable. RESULTS: The cohort included 425 patients; 47% were in active labor. We identified 110 triggers. Nine were considered adverse events (risk 2%, 95% confidence interval [CI] 1–4%, rate 0.8 events per 100 patient days), and six were preventable (risk 1%, 95% CI 0–3%, rate 0.5 events per 100 patient days). The remaining triggers included 14 potential adverse events (risk 3%, 95% CI 2–5%, rate 1.3 events per 100 patient days). No adverse event resulted in permanent disability or death. Adverse events and potential adverse events were most commonly “system” problems, such as unavailable staff or operating rooms, or poor fetal outcomes, such as trauma to the newborn. CONCLUSION: Serious adverse events occur infrequently on an obstetric service. However, important quality problems are common and should be targeted for improvement. LEVEL OF EVIDENCE: II-2

Graduate Medical Education and Patient Safety: A Busy—and Occasionally Hazardous—Intersection

Quality Grand Rounds is a series of articles designed to explore a range of issues related to health care quality and patient safety. The articles present actual cases using a format that integrates traditional medical case histories with results of root-cause analyses and, where appropriate, anonymous interviews with the involved patients, physicians, nurses, and risk managers. Cases do not come from the discussants home institutions. This is the 13th and final case in the series, which began in the 4 June 2002 issue. Summary of the Case An 88-year-old woman was admitted to a teaching hospital early in the academic year with a mild episode of acute pancreatitis. After initial clinical improvement, the patients condition deteriorated and she subsequently died. Her death was partly attributable to a delayed diagnosis of small-bowel obstruction and illustrated problems in sign-outs and handoffs, the supervision of trainees, and knowing when to call for help. The Case Mrs. L., an 88-year-old woman with a history of hypertension and angina, woke up shortly after midnight with epigastric pain and vomiting. Her serum lipase level was substantially elevated at 2000 U/L, and a computed tomography scan of her abdomen revealed mild inflammation at the head of the pancreas and multiple small gallstones. She was admitted with a diagnosis of acute pancreatitis and was prescribed bowel rest, intravenous fluids, and small doses of morphine. The next day, Mrs. L.s pain had markedly lessened and her serum lipase level had decreased to 136 U/L, so her diet was advanced. On hospital day 3, Mrs. L. reported increased epigastric pain after breakfast. Intravenous fluids were resumed, and she was given nothing by mouth. Her pain again improved quickly, so the team restarted a clear liquid diet that same evening. On hospital day 4, a Friday before one of the first weekends in the academic year, the patient had no appetite. Her intern wondered whether the patients abdomen had become more distended but noted no other concerning findings. On afternoon sign-out rounds, the attending physician, Dr. A., thought that the patients stuttering course warranted reassessment and took the team to her bedside. The patient was in no distress, but her abdomen felt firmer and more protuberant. Dr. A. instructed the intern to recheck the serum lipase level and to obtain plain films of the abdomen. If the radiographs revealed ileus or obstruction, the attending physician wanted the on-call intern, Dr. I., to place a nasogastric suction tube. Weekend Effects The initial management of the patient reflects the treating clinicians understandable expectation of a rapid recovery from mild pancreatitis. A common cognitive trap is anchoring bias, in which the clinicians first impressions exert undue influence (1, 2), preventing consideration of alternative diagnoses even in the face of substantial disconfirming evidence. The attending physician avoided this trap when he recognized that the patients hospital course had diverged from his initial expectation and that it warranted reassessment. Moreover, Dr. A. harnessed a valuable teaching opportunity by bringing his team to the patients bedside, rather than merely instructing them to pursue additional diagnostic testing. This bedside assessment occurred on Friday afternoon before one of the first weekends in the academic year, bringing to mind the July phenomenon, the purported increase in complications associated with the arrival of new trainees. Although anecdotes abound, the literature does not clearly identify treatment in July as a risk factor for poor outcomes (37). The upcoming weekend, however, should be mentioned. Two studies (8, 9) have found increased deaths on weekends for patients whose treatment depends on rapid availability of services and personnel. In addition to the potential lack of available services, weekends involve extended periods of physician cross-coverage. In 1 study, such coverage increased the risk for preventable adverse events 3-fold (10). Thus, Dr. A. probably regarded Fridays bedside evaluation as an important opportunity for team members on call for the weekend to lay eyes on Mrs. L. The Case, Continued The results of the serum lipase test, which were in the normal range, were returned from the laboratory early Friday evening. Abdominal radiographs were taken at 4:30 p.m. but were not reviewed. Call at this hospital did not occur as a team. One intern (sometimes accompanied by a medical student) took call for each medical team. A senior resident from 1 of the teams would be in house as a backup for all of the interns but also would see new patients in the emergency department or from other services. Dr. R., the senior resident on Mrs. L.s team, had not been on call with Dr. I. Friday night but was on call Saturday. When Dr. R. arrived Saturday morning, she immediately asked about the abdominal films and the patients overnight course. Dr. I. acknowledged that he had forgotten to review the films. After signing out the other patients to the new on-call team, Dr. I. reviewed the radiographs with a radiologist who noted distended loops of small and large bowel with air-fluid levels in the small bowel, consistent with ileus or mechanical obstruction. Dr. I. paged Dr. R., who was busy seeing patients in the emergency department. Dr. R. asked whether Mrs. L. still looked stable; Dr. I. said yes. Dr. R. told him to make sure Mrs. L.s nurse inserted a nasogastric tube promptly. If the nurse could not do it, Dr. I. should do so himself. A few minutes later, Dr. R. met with Dr. A. (the attending physician), who had been in the hospital since 7:00 a.m. seeing patients admitted to his service the night before. Because of an unexpected problem with child care, Dr. A. was rushing to leave the hospital by late morning. Before leaving, he planned to ask Dr. R. about any new issues on the old patients and perform an urgent surgical consult. He would return to complete his rounds in the late afternoon. Dr. A. asked Dr. R. about Mrs. L. The resident described Dr. I.s oversight and stated that Dr. B. (the on-call intern) or Ms. S. (the on-call medical student) would promptly insert a nasogastric tube. After instructing the resident to have whoever placed the tube page him if the patient looked worse than she had on the previous day, Dr. A. completed his surgical consult and left the hospital. Sign-Outs and Handoffs Forgetting to follow up on the abdominal radiographs may have partially resulted from Dr. I.s inexperience as a July intern. However, similar failures are expected at all levels of practice. Surely every clinician has found himself or herself driving home at the end of a long day only to remember an important radiograph that was not reviewed, a consult that was not done, or an urgent patient telephone call that was not returned. Such slips represent expected failings of human memory, not deficiencies of knowledge or skill (11). Structured rounding and sign-out systems provide solutions to the problem of relying on human memory to manage long to-do lists and track key clinical information. One hospital implemented a computerized sign-out system that combined available data from the existing clinical information system, such as current medications and allergies, with more detailed information entered by residents, such as problems and to-do lists (12). Before the sign-out system, cross-coverage represented a significant risk factor for preventable adverse events (hazard ratio, 5.2 [95% CI, 1.5 to 18.2]). After implementation, this hazard ratio decreased to 1.5 and was no longer statistically significant. Another institution implemented a similar computerized sign-out system and significantly reduced the number of patients the team forgot to see on rounds (2.5 vs. 5 overlooked patients/team per month; P< 0.001) (13). Information technology offers another method of facilitating follow-up for important test results. Clinical laboratories and hospitals with advanced information systems are increasingly looking for ways of pushing important test results to clinicians instead of clinicians having to pull them (14). Developing such functionality for electronic records will probably confer demonstrable benefits, as with the computerized sign-out systems discussed previously. As potentially attractive as these computerized solutions are, they do not address the deeper problem of poor communication (15, 16). At some point during the rounds-turned-bedside evaluation, Dr. A. mentioned that the abdominal radiograph should be reviewed later that evening. He probably regarded it as self-evident that this review (to exclude bowel obstruction) was urgent and thus probably did not emphasize to Dr. I. that reviewing this radiograph represented the single most important to-do item for him on call. Even ignoring the possibility that an inexperienced intern might not immediately appreciate the urgency of this follow-up item, the absence of robust and standardized communication practices in most clinical settings provides numerous opportunities for errors due to ineffective information transfer. Residents in 1 study (16) highlighted the problems that arise as a result of wide variation in sign-out practices, from basic elements of format, such as whether communication occurred in person or through annotated patient lists left in on-call rooms, to elements of content, such as documenting medication changes and important changes in clinical status. Thus, the adoption of standard sign-out formats to ensure the communication of all pertinent information may prove as important as acquiring computerized rounding aids (12, 13). The situationbackgroundassessmentrecommendation (SBAR) format has been recommended as a template for improving communication among clinical personnel (17). However, in some settings, such simple techniques as summarizing key points may suffice. For instance, once the team had left

Learning from our mistakes: Quality grand rounds, a new case-based series on medical errors and patient safety

The case presentation has long been revered as an educational tool for physicians. Beginning early in medical school, many students eagerly devour the case presentations (often called clinical-pathologic conferences, or CPCs) in major medical journals, admiring both the marvelous complexity of the clinical details and the virtuoso performances of the invited discussants (1). Over the past 20 years, the case presentation and discussion method has become more varied and nuanced. In clinical problem-solving exercises, cases were presented to expert discussants in aliquots, giving learners a chance to observe the experts reasoning process (2). This format, as well as the incorporation of patients and providers perspectives into case protocols in two recent series (3, 4), has expanded the scope and utility of case presentations in medical education. These changes dovetailed nicely with a trend in many medical schools to replace lectures with case-based learning (5). Case-based learning can be tremendously instructive and stimulating but can also carry a subtle educational threat. By emphasizing the great case (usually the more unusual and complex the case, the better) and the remarkable reasoning abilities of the master clinician, learners may assimilate the seductive but unrealistic message that a physicians individual knowledge and skill play the dominant role in determining patient outcomes. The patient safety corollary to this message is that poor outcomes primarily reflect deficiencies in the physicians knowledge base or cognitive and technical abilities. This unrealistic expectation of perfection undoubtedly contributes to physicians traditional reluctance to discuss errors (6) and tends to distort these discussions when they do occur, such as in the morbidity and mortality (M&M) conferences held in many hospitals. Although designed to provide a setting in which mistakes can be discussed openly and honestly, most M&M conferences follow one of two paths, neither of which optimally promotes the goal of learning from errors. The conference either gradually but inexorably mutates into a CPC-like great case conference, or an error is presented followed by the excoriation of an individual physician for his or her failings (more common in the surgical specialties and popularized by many television and movie productions). As our understanding of patient safety and error reduction has matured, we now realize that, although the M&M-cum-CPC conference simply sidesteps the consideration of errors, the find-and-punish-the-bad-apple approach may be equally unproductive in efforts to decrease errors that harm patients (7, 8). Catalyzed by the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System, the medical system recently began to respond to the tremendous public outrage over medical errors (9). Many of the responses focused on reporting systems and other methods of gathering data about the problem (10, 11). Several important articles, monographs, and books highlighted some of the key issues in patient safety and the conceptual underpinnings of quality improvement, often drawn from industries unrelated to health care, such as aviation and nuclear power (12, 13). However, for reasons that include liability issues and a medical culture that has discouraged open discussion of mistakes, the power of the individual case presentation, so important in the physicians clinical medicine education, has not been harnessed to educate providers about medical errors. In this issue, Annals launches a new series, Quality Grand Rounds. In it, we present articles and companion conferences in a format similar to that of clinical problem-solving cases. Each article describes an actual case involving a medical error or quality issue but does not identify the patient, providers, or institution. Although much of the case material is clinical (that is, drawn from the medical record), in a few cases, the involved institutions allowed us (the series editors) to observe their internal fact-finding and problem-solving process, known as root-cause analysis. In addition, we often interviewed key participants (including the patient, doctor, nurse, or risk manager) to be sure we could convey a full understanding of the events. Parts of these interviews are included in several of the case presentations in Annals, and additional information can be found accompanying the on-line version of the articles. Each case was presented to the discussants in a conference format (Quality Grand Rounds), and the manuscripts were revised to reflect the issues raised at the conferencesincluding those discussed during the question-and-answer sessions. In contrast to traditional CPCs, in which the discussant focuses on diagnosing the disease based on the patients presenting symptoms, the focus in Quality Grand Rounds is on diagnosing the systems problems that led to a serious error or adverse outcome for the patient. Our discussants, who are national experts in the relevant patient safety and quality issues, help the reader understand the cause of the errors, frame them in the context of what we know about patient safety, and suggest ways of decreasing the risk to future patients of similar errors. Throughout the series, discussants emphasize not only individual errors but also system failings that allowed the inevitable human fallibility to reach the patient and cause harm (13-15). For example, in this issues The Wrong Patient, Drs. Chassin and Becher describe the 17 errors that came together to allow one patient to receive an invasive procedure intended for another (16). Although neither the authors nor the other discussants in the series deny or sugarcoat the individual errors, they identify the failure or absence of systems to catch patient misidentifications and a cultural milieu that provides rich soil for system problems and individual mishaps to blossom into errors. Throughout the series, readers will be introduced to patient safety concepts, such as systems thinking, the culture of safety, root-cause analysis, and human-factors engineering, as well as to controversies in the field, including the central question, What is an error?. This series, which will appear in every three to four issues of Annals, is supported by the California HealthCare Foundation as part of its Quality Initiative. We are also grateful to our consulting editor, Kathy Dracup, RN, DNSc; our discussants; and our conference audiences for their participation and interest. The Annals Editorsparticularly Drs. Harold Sox, Cynthia Mulrow, David Goldmann, and Frank Davidoffhave been unstinting supporters of this effort, demonstrating their commitment to educating physicians and trainees about quality and patient safety. Our largest debt, of course, is owed to the patients, family members, providers, and institutions that shared their stories with us. Almost to a person, participants told us that they did so in the hope that their tale would help prevent errors from harming other patients. Perhaps surprisingly, they reflected on their experiences with equanimity and even a sense of humor. For instance, the patient described in this issue, who underwent an unneeded invasive cardiac procedure because her name was similar to that of the intended patient, not only emphasized her desire to protect others but went on to say, I was glad that my heart checked out OK. We hope that Quality Grand Rounds does justice to this extraordinary spirit of generosity and makes a difference in promoting the systems and cultural changes needed to make health care safer.

Overestimation of clinical diagnostic performance caused by low necropsy rates

Background: Diagnostic sensitivity is calculated as the number of correct diagnoses divided by the sum of correct diagnoses plus the number of missed or false negative diagnoses. Because missed diagnoses are generally detected during clinical follow up or at necropsy, the low necropsy rates seen in current practice may result in overestimates of diagnostic performance. Using three target conditions (aortic dissection, pulmonary embolism, and active tuberculosis), the prevalence of clinically missed cases among necropsied and non-necropsied deaths was estimated and the impact of low necropsy rates on the apparent sensitivity of antemortem diagnosis determined. Methods: After reviewing case series for each target condition, the most recent study that included cases first detected at necropsy was selected and the reported sensitivity of clinical diagnosis adjusted by estimating the total number of cases that would have been detected had all decedents undergone necropsy. These estimates were based on available data for necropsy rates, time period, country (US v non-US), and case mix. Results: For all three target diagnoses, adjusting for the estimated prevalence of clinically missed cases among non-necropsied deaths produced sensitivity values outside the 95% confidence interval for the originally reported values, and well below sensitivities reported for the diagnostic tests that are usually used to detect these conditions. For active tuberculosis the sensitivity of antemortem diagnosis decreased from an apparent value of 96% to a corrected value of 83%, with a plausible range of 42–91%; for aortic dissection the sensitivity decreased from 86% to 74%; and for pulmonary embolism the reduction fell only modestly from 97% to 91% but was still lower than generally reported values of 98% or more. Conclusions: Failure to adjust for the prevalence of missed cases among non-necropsied deaths may substantially overstate the performance of diagnostic tests and antemortem diagnosis in general, especially for conditions with high early case fatality.

Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? No

Obtaining definitive evidence on the effects of large scale interventions can be difficult. Bernard Crump (doi: 10.1136/bmj.a145) believes that implementation with careful monitoring is justified but Seth Landefeld and colleagues argue that acting without proof is both costly and potentially damaging to health

Quality Grand Rounds: The Case for Patient Safety

In this issue, we present the 13th and final article in the Quality Grand Rounds series, the case of an elderly woman admitted to a teaching hospital early in the academic year with a mild episode of acute pancreatitis (1). Despite initial improvement, her condition deteriorated over the course of several days; her ultimate death was attributable to delayed diagnosis and management of a small-bowel obstruction. The case highlights problems in resident supervision, fumbled handoffs, adverse consequences of housestaff duty-hour limitations, and deficient safety systems. As with many cases of medical errors, the explanation is messy and multifaceted, resisting a clean, simple fix. The case stands as a fitting bookend to the entire Quality Grand Rounds series. Our first case, The Wrong Patient, described a woman who received an invasive electrophysiology procedure intended for a patient with a similar last name (2). In their discussion of that case, Chassin and Becher identified 17 individual mistakes, none remarkable or difficult to understand in isolation. Together, they provided the necessary ingredients for a breathtaking error. In between, we have published 11 other cases that illustrate the breadth of the patient safety field (313). Some casesa patient dies after a nurse mistakenly flushes an intravenous line with insulin instead of heparin, another dies of an air embolism after incorrect removal of a central catheterbeg for such systems fixes as computerized physician order entry, bar coding, checklists, readbacks, and competency-based credentialing (3, 10). Other casesa patients hospitalization from hell, for example (6)demonstrate that safe systems need to be accompanied by an institutional culture that prizes safety and quality. In fact, 7 years after the Institute of Medicines report To Err Is Human catalyzed the modern patient safety movement (14), we have come to recognize that the solutions to medical errors must be as distinct as the problems themselves. It is no longer sufficient for researchers to simply demonstrate that a targeted intervention (for example, computerized physician order entry, teamwork training, higher nurse-to-patient ratios, or housestaff duty-hour limits) leads to improved safety. To be useful to decision makers in a specific institution, studies should help them to choose among the many potentially effective interventions in the face of limited resources, the quirks of a specific clinical environment, and a finite institutional capacity for change. Efforts to use evidence to help inform these prioritization decisions are in their infancy (15). In addition to the challenge of helping institutions to choose among several effective safety interventions, the safety field has begun to appreciate the frequency of unintended consequences of safety interventions. Both the case in this issue and our penultimate case (in which a bar-coded wristband identification system backfired when 2 patients wristbands got mixed up [13]) demonstrate that even easy fixes like housestaff duty-hour limitations and bar coding may cause unforeseen problems as they migrate from theory to widespread application. Several recent articles describing the negative consequences of computerized physician order entry amplify the same theme (1618). As the patient safety field matures, these unanticipated effects should no longer surprise us. Initial studies are often conducted by investigators who are passionate about a given practice, take place in relatively controlled settings, and have unusually robust funding and experienced support personnel (19). Although subsequent, more real-world studies with negative findings are often critiqued as simply illustrating problems with implementation (20), they may more accurately reflect the efficacy of the practices under natural conditions. Accordingly, we ignore them at our own, and our patients, peril. As Shojania and colleagues point out, the solution to these unforeseen consequences is not to eschew innovation for fear of the problems it may bring (1). Rather, it is to take promising technologies and practices, often drawn from other industries, and adapt them to the health care setting, maintaining vigilance to identify these problems if they exist (21). Even as the cases in the Quality Grand Rounds series illustrated the range and complexity of medical errors, we aimed for them to be a play within a play, demonstrating the unique power and drama of the case presentation as a patient safety teaching tool. Although one can readily comprehend the value of quality measurement for simple processes with demonstrated beneficial outcomes (such as the use of aspirin or -blockers in patients with acute myocardial infarction), no measurement system can capture the richness and nuance of a complex case of medical error. For example, even a relatively detailed chart review of the case discussed by Shojania and colleagues might have revealed an elderly patient who died after being admitted to the hospital for pancreatitis. Furthermore, because the patient did not want heroic measures, her death was peaceful and, for all but a clinically sophisticated reviewer, not entirely unexpected. Yet the analysis of the case demonstrates myriad errors and opportunities for improvement, with a drama and narrative drive that a blackboard full of failure mode and effects analyses (FMEAs) could not possibly match. Such casesand their powerful messageswill come to light only if clinicians feel comfortable bringing them forward. We hope that the series has illustrated the importance of providing safe venues for open, honest discussions of medical errors. (Parenthetically, in several years of publishing anonymous cases of medical errors in Annals, in a popular book [22], and in a federally sponsored Web-based journal [AHRQ WebM&M], we have not had a single uncomfortable inquiry from a journalist or an attorney. We believe that concerns about legal discovery of case discussions in public venues are often overblown.) The recently passed patient safety legislation (which calls for federally sanctioned Patient Safety Organizations that will protect storytelling and data sharing from legal discovery [23]) represents a positive step in the effort to facilitate unencumbered discussions of medical errors. We end the series with profound thanks to the many physicians, nurses, pharmacists, administrators, and patients who shared their stories with us in the hope that doing so might prevent another error. We are grateful to Annals for hosting the Quality Grand Rounds series and to the California HealthCare Foundation for its generous support. Although the series has concluded, we plan to publish a book containing the cases and additional commentary, which may serve as an ongoing resource for the field. We hope that the cases have not only been useful for their specific content but also that they have encouraged institutions and providers to share their own cases in a new way, using them to sow the seeds of systems and culture changes to ensure that patients receive safe, high-quality care.